^p^    ^<.* 


y  ^K  \.y 


Public  Health  Is  Purchasable.     Within  Natural  Limitations    Any  ICommunity'ilCan 
Determine   Its    Own    Death    Rate 


MANUAL 

FOR 

PUBLIC  HEALTH  NURSES 


HERMANN  M.  BIGGS,  M.D. 
Commissioner 


I      NEW  YORK 

STATE  DE1'"AR'1'MLN1  OF  HLALTH 

ALBANY,  N.  Y 
1920 


^ 


y 


CONTENTS 


Chapler        '  I  Public  Health  Nursing  in  New  York  State 5 

'  II  Sanitary  Inspection 22 

III  Pure  Milk  Supplies 38 

IV  Pure  Wat«r  Supplies 50 

V  Disposal  of  Sewage 66 

VI  Control  of  Flies,  Mosqutoes  Other  Insects  and  Vermin 87 

'  VII  The  Nurse  and  Commun"cable  Diseases 94 

•VIII  Public  Health  Nursing  and  Tubercu  osis 106 

IX  Cooperation  of  Health  and  Educat  onal  Authorities  in  the  Con- 
trol of  Communicable  Diseases 130 

X  The  Public  Health  Laboratory 138 

XI  Laboratory  Service 140 

-    XII  The  Nurse  in  Public  Health  Education 150 

<XIII  What  the  Nurse  Should  Know  About  Vital  Statistics 160 

-XIV  The  Public  Health  Nurse  and  Child  Welfare  Activities 173 

XV  Supervision  of  Midwives 185 

XVI  Health  Supervision  of  the  School  Child 192 

XVII  Mental  Hygiene 219 

XVIII  Hygiene  of  Home  and  Workshop 224 


502«i.'J5 


RV 


INTRODUCTION 


With  the  large  increase  in  the  number  of  public  health  nurses 
employed  in  New  York  State,  there  has  developed  a  distinct  need 
for  a  compilation  of  information  regarding  the  work  of  the  public 
health  nurse  in  all  its  various  phases  to  which  the  nurse  can  refer 
when  any  question  arises  as  to  the  scope  of  her  work,  and  her  legal 
limitations.  At  the  risk  of  being  too  voluminous  it  has  been  broad- 
ened to  include  various  information,  which,  while  perhaps  outside 
the  actual  field  of  her  activities,  is  nevertheless  closely  related  to 
certain  branches  of  her  work  and  about  which  she  should  be  well 
informed. 

In  a  field  which  is  developing  so  rapidly,  it  is  inevitable  that 
some  important  features  may  have  been  overlooked  or  insuffi- 
cietly  discussed.  Certain  aspects  already  well  covered  in  avail- 
able printed  from  have  been  omitted.  It  is  therefore  earnestly 
hoped  that  those  who  use  this  book  will  feel  free  to  indicate  to  this 
Department  wherein  it  may  fail  in  any  way  to  meet  their  needs. 

Securing  a  Nurse 
One  of  two  reasons  usually  influences  a  community  to  employ 
a  public  health  nurse;  first,  the  knowledge  of  the  existence  of  a 
considerable  amount  of  sickness  and  physical  disability  in  the 
municipality  for  which  no  adequate  remedial  care  is  provided; 
or  second,  the  belief  that  such  a  condition  may  exist  of  which  the 
actual  extent  is  unknown,  with  the  conviction  that  if  existing  the 
situation  should  be  corrected.  A  nurse  is  thus  often  employed 
to  make  a  survey  of  health  and  sanitary  conditions  and  report 
thereon  to  the  agency  employing  her.  As  a  result  of  such  report 
a  campaign  may  be  organized  to  provide  the  machinery  for  the 
correction  of  the  conditions.  This  may  call  for  a  consolidated 
health  district,  a  hospital  or  free  clinic  of  some  sort,  or  for  the 
permanent  employment  of  a  public  health  nurse. 

[iii] 


Iv  State  Bepaktment  of  Health 

To  sec'ure  the  funds  necessary  for  these  health  activities,  some 
sort  of  a  publicity  campaign  is  usually  essential.  It  matters  little 
whether  the  group  to  be  convinced  be  a  legislative  committee,  a 
county  board  of  supervisors  or  the  individual  voters,  as  in  a  refer- 
endum; the  method  utilized  is  that  of  a  powerful,  convincing 
appeal  with  provision  for  immediate  enthusiastic  action.  In 
health  conservation  propaganda  one  must  not  forget  that  the  public 
will  demand  and  usually  get  what  it  really  wants.  The  problem 
becomes,  then,  to  make  the  public  desire  this  additional  health 
conservation  machinery.  The  recent  world  war  demonstrated 
that  even  enemies  are  glad  to  work  together  for  a  common  cause. 
With  a  convincing  publicity  campaign,  the  aim  was  to  "go  over 
the  top"  in  contributions.  To  secure  this  form  of  publicity  and 
this  reaction  requires  hard  work  by  someone,  and  the  particular 
sort  of  ability  which  makes  certain  that  channels  for  action  are 
at  hand  when  emotion  is  at  its  height.  Every  community  has 
had  practice  in  this  work  during  the  v*^ar  and  knows  how  these 
matters  are  handled.  The  method  for  securing  financial  support 
for  a  nurse  is  not  greatly  different  from  that  employed  in  securing 
contributions  for  starving  war  orphans  or  Liberty  Loans.  Pro- 
vision must  bo  made  so  that  the  supporters  of  the^  work  shall  in- 
dividually continue  to  receive  some  personal  satisfaction  from 
their  efforts,  otherwise  their  interest  and  continued  support  can 
not  be  looked  for. 

Local  chapters  of  the  American  Eed  Cross  are  authorized 
through  the  Chapter  Committee  on  Nursing  Activities  to  develop, 
or  aid  in  developing  within  their  districts,  such  public  health  nurs- 
ing service  as  is  desirable  and  meets  the  approval  of  the  Chapter 
Executive  Committee.  Such  public  health  nursing  sennc©  is  not 
initiated  or  supported  by  the  Red  Cross  except  to  cooperate  with 
or  aid  other  established  agencies. 

Reports  and  Records 

j\Ii'.  Harrington  Emerson  has  defined  a  record  as  a  ''statement 
of  fact/'  and  a  report  as  ''an  expression  of  opinion."  Among 
the  necessaiy  qualities  of  a  good  n^port  according  to  this  author 
are  several  which  a  pul)li('  health  nurse  will  find  especially 
."pplicabk. 


Introduction  v 

"  The  qualities  of  a  good  record. —  it  should  be  necessary,  it 
should  be  authorized,  it  should  be  reliable  and  sufficiently  accurate, 
it  should  be  available,  it  should  be  adequate  giving  essentials, 
it  should  be  simple,  very  clear  and  easy  to  understand,  it  should 
be  initiated  at  the  moment  the  event  is  occurring,  it  should  be 
easy  to  make,  and  it  should  be  signed  or  certified  by  the  maker." 

Very  few  ready  made  record  cards  altogether  fit  requirements 
in  rural  and  other  small  communities.  Many  nurses  w^ill  prefer 
to  use  blank  cards,  developing  their  own  system  of  records  in  ac- 
cordance with  the  needs  of  their  particular  service.  When  this 
is  undesirable  certain  standardized  cards  are  available.  Probably 
the  best  system  of  cards  procurable  for  general  nursing  work  is 
that  which  has  been  prepared  by  the  National  Organization  for 
Public  Health  Nursing. 

To  be  of  value  reports  should  show  the  nature,  scope  and  human 
side  o£  the  work.  They  should  aim  to  show  what  progress  has 
been  made  and  foreshadow  changes  about  to  be  necessitated  because 
of  growth  of  the  work.  A  daily  record  of  work  done  including 
time  and  expenses,  should  be  kept.  Reports  should  be  made 
regularly  to  the  health  officer  or  proper  authority,  and  as  regularly 
published,  generally,  in  local  newspapers.  This  is  essential  for 
securing  continued  interest  and  cooperation  from  the  public,  with- 
out whose  support  no  nurse's  work  can  be  of  value. 


I 


CHAPTER  I 
Public  Health  Nursing  in  New  York  State 

Public  health  nursing  is  a  comparatively  new  institution. 
Progressive  sanitary  authorities  now  admit  that  the  enforcement 
of  sanitary  laws  for  the  prevention  of  disease  has  its  distinct  limi- 
tations, and  that  something  more  is  needed  for  the  protection  of 
the  public.  Ignorance  in  the  home  still  exists  even  with  the  best 
possible  sanitary  surroundings  obtainable  by  police  power,  and 
the  conditions  springing  from  such  ignorance  remain  a  constant 
menace  to  the  public  health.  This  fact  was  first  recognized  in  the 
tuberculosis  campaign,  and  later,  in  the  campaign  against  infant 
mortality,  was  fully  realized.  It  was  found  that  instruction  in 
personal  hygiene  in  the  home  is  urgently  needed  both  by  the 
tuberculous  patient  in  the  one  case  and  by  the  mother  in  the 
other,— by  the  patient  in  learning  how  to  avoid  the  spread  of 
infection,  and  by  the  mother  in  learning  how  to  care  for  her  child. 
Such  instruction  was  seen  to  be  the  most  powerful  single  measure 
that  boards  of  health  could  utilize.  Hence  the  institution  of  the 
public  health  nurse  with  her  various  powers,  duties  and  activities. 

Powers 
Source  of  power.     The  employment  of  nurses  in  the  promotion 

of  public  health  is  authorized  in  New  York  State  by  (1)  the 
public  health  law;  (2)  the  education  law;  and  (3)  the  county 
law,  as  follows: 

Section  4-a  (12)  public  health  law:  "The  commissioner  of 
health,  whenever  he  may  deem  it  expedient  so  to  do,  may  employ 
such  number  of  public  health  nurses  as  he  may  deem  wise  within 
the  limits  of  his  appropriation  and  may  assign  them  from  time  to 
time  to  such  sanitary  districts  and  in  such  manner  as  in  his  judg- 
ment will  best  aid  in  the  control  of  contagious  and  infectious  dis- 
ease and  in  the  promotion  of  public  health." 

Section  21-c  public  health  laiv:  "Each  health  officer  oi* 
other  official  exercising  similar  duties,  by  whatsoever  official  desig- 
nation he  may  be  known,  shall  have  power  to  employ  such  number 

[5] 


6  State  Departmext  of  Health 

of  public  health  nurses  as  in  his  judgment  may  be  necessary 
within  the  limits  of  the  appropriation  made  therefor  l)y  the  city, 
town,  or  village.  They  shall  work  under  the  direction  of  the 
health  officer  and  they  may  be  assigned  by  him  to  the  reduction  of 
infant  mortality,  the  examination  or  visitation  of  school  children 
or  children  excluded  from  school,  the  discovery  or  visitation  of 
cases  of  tuberculosis,  the  visitation  of  the  sick  who  may  be  unal)le 
otherwise  to  secure  adequate  care,  the  instruction  of  members  of 
households  in  which  there  is  a  sick  person,  or  to  such  other  duties 
as  may  seem  to  him  appropriate." 

Section  570  education  law:  "Medical  inspection  shall 
include  the  service  of  a  trained,  registered  nurse,  if  one  is 
employed." 

Section  571  education  law:  "Any  such  board  of  trustees  may 
employ  one  or  more  school  nurses,  who  shall  be  registered  trained 
nurses  and  authorized  to  practice  as  such.  Such  nurses  being 
so  employed  shall  aid  the  medical  inspector  of  the  district  and 
shall  perform  such  duties  for  the  benefit  of  the  public  schools 
as  may  be  prescribed  by  such  inspector.  A  medical  inspector  or 
school  nurse  may  be  employed  by  the  trustees  or  boards  of  educa- 
tion of  two  or  more  school  districts." 

Section  47  (9)  county  law  {Am'd  in  1918)  :  "  The  board 
of  managers  (of  a  county  tuberculosis  hospital)  .  .  .  shall 
employ  a  county  nurse  or  an  additional  nurse  or  nurses,  if  it 
deems  necessary,  for  the  discovery  of  tuberculosis  cases  and  for 
the  visitation  of  such  cases  and  of  patients  discharged  from  the 
hospital,  and  for  such  other  duties  as  may  seem  ai)propriate ; 
and  may  cause  to  be  examined  by  the  superintendent  or  one  of 
his  staff  suspected  cases  of  tuberculosis  reported  to  it  by  the 
county  nurse  or  nurses  or  by  physicians,  teachers,  employers, 
heads  of  families  or  others  and  it  may  take  such  other  steps  for 
the  care,  treatment  and  prevention  of  tuberculosis  as  it  may  from 
time  to  time  deem  wise.  In  cases,  hoAvever,  where  it  is  not  manda- 
tory 1o  establish  a  county  tuberculosis  hospital  and  no  board  of 
managers  has  been  provided,  tlie  lioard  of  supervisors  shall  have 
the  power  to  a|)i)<)iiit  and  employ  such  nurs(^  or  additioual  nurse 
or  nurses,  and  appointments  heretofore  made  liy  boards  of  super- 
visors in  such  cases  are  hereby  ratified,  confirmed  and  legalized." 


Public  Health  Nursikg  7 

Qualifications 

In  accordance  with  section  2-c  of  the  public  health  law,  the 
Public  Health  Council  has  prescribed  the  following  qualifications 
for  supervisory  public  health  nurses: 

"Supervising  public  health  nurses  employed  by  the  state 
department  of  health  shall  possess  the  following  qualifications: 

(1)  They  shall  be  registered  nurses; 

(2)  They    shall    submit    evidence    satisfactoiy   to    the    pul)lic 

health  council  of  training  and  experience  of 
not  less  than  two  years  after  graduation,  in 
one  or  more  of  the  following  lines  of  work : 

(a)  Maternity  work; 

(b)  Infant  welfare  work; 

(c)  Social  service; 

(d)  Tuberculosis  work; 

(e)  Care  of  communicable  disease;  and 

(f)  School  nursing. 

(3)  They  shall  be,  when  appointed,  not  less  than  twenty-five 

years  of  age." 

To  practice  as  a  registered  nurse  (R.  X.)  in  the  State  of  Xew 
York  it  is  necessary  to  comply  vnth  the  requirements  of  sections 
250  to  253,  inclusive,  of  the  public  health  law.  Certificates  aro 
issued  by  the  regents  of  the  state  of  Xew  York  to  the  nurse  wlio 
successfully  meets  the  conditions  imposed.  A  civil  service 
examination  is  required  for  the  permanent  api^ointmcnt  of  a 
nurse  by  state  or  city  departments  of  health,  or  by  a  district 
whose  officers  are  classified  l)y  the  State  Civil  Service  Commission. 

A  public  health  nurse  must  possess  not  only  nursing  but  social 
and  administrative  qualifications.  In  addition  to  training  in  the 
care  of  the  sick  she  must  have  experience  in  tlie  recognition  and 
care  of  various  diseases,  especially  communicable  diseases.  She 
must  be  practical,  and  her  instructions  should  be  combined 
with  tact,  encouragement  and  assistance.  The  latter  may 
come  first  in  placing  the  patient  in  touch  with  a  tuber- 
culosis clinic  or  charitable  organization,  making  arrangements 
for  admission  to  a  hospital  or  a  sanatorium,  and  the  like. 
She  must  be  able  to  distinguish  between  what  is  essential  and 


8  State  Departmext  of  Health 

what  is  not,  for  many  mothers  and  families  whom  she 
will  instruct  will  probably  be  poor,  ignorant  and  busy,  with 
neither  time  nor  inclination  to  do  more  than  what  is  absolutely 
necessary.  A  public  health  nurse  must  have  not  only  technical 
training  in  nursing  the  sick  —  for  though  she  may  perform  but  a 
limited  amount  of  bedside  nursing  work,  she  must  be  able  to 
instruct  others  —  but  she  must  also  have  social  qualifications. 
Her  work  is  often  with  well  people, —  parents,  teachers, 
superintendents  of  institutions,  and  others  who  are  respon- 
sible for  dependents  under  them,  and  with  members  of  societies 
and  officials  upon  whom  rests  the  responsibility  for  making  new 
sanitary  regulations  and  for  improving  health  conditions.  She 
must  be  able  to  impress  these  people  with  the  value  of  her  work, 
and  the  desirability  of  her  ideals  by  the  force  of  her  personality. 
She  must  be  self-reliant  and  businesslike  in  her  methods,  able  to 
cope  with  the  various  health  problems  which  she  meets  in  the  home, 
in  the  office,  and  in  the  social  community.  She  must  have  the  gift 
of  making  friends,  of  getting  others  to  work  willingly  and  cheer- 
fully in  cooperation  with  her,  of  inducing  parents  to  follow  her 
directions,  and  members  of  philanthropic  societies  and  health  and 
welfare  associations  to  give  her  active  support.  She  must  keep 
full  and  accurate  records  of  her  work  and  should  be  able  to  inter- 
pret them  in  an  interesting  and  convincing  manner.  Finally, 
she  must  have  good  health  herself  and  a  strong  physique  to  enable 
her  to  endure  the  strain  of  constant  house  to  house  visitation  and 
frequent  traveling  from  place  to  place. 

Duties 

The  primary  duties  of  the  public  health  nurse  are  to  advise  and 
instruct  —  to  advise  and  show  others  how  to  care  for  the  sick, 
to  secure  for  them  adequate  care,  and  1o  instruct  people  how  to 
avoid  sickness  by  attention  to  personal  hygiene.  Bedside  nursing 
of  the  sick  poor  is  not  one  of  the  primary  functions  of  the  public 
health  nnrs<\  sncli  work  being  usually  performed  by  the  "visit- 
ing" nurse;  but  the  public  health  nurse  should  maintain  con- 
stant cooperation  with  such  nurses  and  refer  to  them  any  cases 
which  need  .special  nursing  attention. 

Among  the  important  duties  which  are  performed  by  the  State 
Department  of  Health  nurses  are  the  following: 


Public  Health  Nursing  9 

x(l)  Discovery  and  investigation  of  cases  of  communicable 
disease ; 

^  (2)  Sanitary  surveys  and  the  collection  of  information  for 
specific  objects,  such  as  the  discoveiy  of  tuberculosis  cases,  the 
prevalence  of  venereal  disease,  and  the  investigation  of  home 
conditions  affecting  infant  mortality; 

(3)  The  after-care  of  cases  of  poliomyelitis; 

(4)  Urging  the  employment  of  nurses  in  industrial  establish- 
ments and  cooperation  in  the  work  of  industrial  nurses ; 

(5)  The  inspection  aiid  supervision  of  midwives; 

:.--  (6)   Instruction  in  conduct  of  infant  welfare  stations  and  tuber- 
culosis dispensaries; 
■  (T)   The  registration  of  unreported  births; 

(8)  School  inspection;  in  cooperation  with  the  school  medical 
inspector ; 

(9)  Conducting  exhibits; 

--(10)   Educational  work,  lectures,  demonstrations,  etc; 
(11)    Supervising  and  instructing  local  public  health  nurses. 

The  duties  which  are  usu.ally  performed  by  public  health  nurses 
employed  by  the  boards  of  health  of  local  municipalities  are: 

(1)  The  discovery  of  mild  or  unrecovered  and  unreported  cases 
of  communicable  disease; 

(2)  The   investigation   and   improvement  of  home   conditions 
which  affect  infant  mortality ; 

(3)  The  conducting  of  infant  welfare  stations; 

(4)  The  securing  of  medical  or  hospital  care  for  the  sick; 

-  (5)    Cooperating  with   social      agencies   in   promoting  public 
health  work,  including  the  control  of  venereal  disease. 

(6)  Cooperating  with  overseers  of  the  poor  in  improving  health 
conditions  among  the  dependent  poor ; 

(7)  Preventive  and  after-care  work  in  poliomyelitis,  cases  of 
mental  defect,  insanity  and  blindness ; 

^'  (8)   Antituberculosis  work; 

(9)   Educational  work,  such  as  instruction  of  Red  Cross  classes 
and  Little  Mothers'  Leagues ; 

i^'lO)   Investigations  of  food  stores,  dairies,  playgrounds,  public 
toilets,  etc. ; 


10  State  Dkpaut.ment  of  Health 

(11)  Assitiug  the  health  officer  in  securing  laboratoiy  speci- 
mens for  diagnostic  purposes. 

(XoTE:  In  Avorking  for  local  boards  of  health,  the  public  health  nurse  is 
under  the  direction  of  the  local  health  oHicer.  When  representing  the  health  officer 
she  acts  as  his  deputy,  and  nurses  employed  by  private  organizations  should  be  so 
deputized  by  local  boards  of  health.) 

The  following  duties  are  usually  performed  by  county  tuber- 
culosis nurses: 

(1)  The  discovery  of  unreported  cases  of  tuberculosis; 

(2)  Enlisting  the  interest  of  physicians  in  the  examination 
and  treatment  of  tuberculous  patients; 

(3)  Studying  the  morbidity  and  mortality  statistics  of  the 
various  municipalities  with  special  reference  to  tuberculosis; 

(4)  Arranging  for  the  admission  of  tuberculous  patients  to 
hospitals  and  securing  the  attendance  of  known  cases  and  contacts 
at  clinics; 

(  5 )  Attending  tuberculosis  clinics ; 

(6)  Home  visitation  and  instruction  of  tuberculous  patients; 

(7)  Giving  lectures  and  demonstrations  on  antituberculosis 
work. 

(Note:  The  director  of  the  county  nurses  is  the  superintendent  of  the 
county  tuberculosis  hospital,  but  she  will  also  be  under  the  direction  of  the 
local  health  officer  in  her  field  work.) 

The  principal  functions  of  the  school  nurse  are  as  follows : 

(1)  The  discovery  and  prevention  of  communicable  diseases 
among  school  children; 

(2)  The  discovery  and  correction  of  physical  defects; 

(8)  The  visitation  and  instruction  of  parents  of  school  chil- 
dren who  have  physical  defects; 

(4)  Giving  simple  routine  treatments  prescribed  by  the  medical 
inspector  and  the  family  physician; 

(5)  Attending  school  clinics; 

(G)   Assisting  the  medical  examiner  of  the  school; 

(7)   Instructing  special  groups  of  children  in  practical  hygiene. 

(Note:  The  school  nurse  works  under  the  immediate  direction  of  the 
medical  inspe-tor  o''  schools,  but  she  should  also  cooperate  with  llie  health 
oliiccM-  and  otlicr  public  health  workcrw. ) 

Leoal  Status  and  Aptiiority 
'    The  ]ml)lif  liealth  nurse  should  bo  familiar  with   the  sources 
from  which  she  derives  her  legal  status  and  authority,   and  by 


Public  Health  Nursing  11 

virtue  of  which  the  various  activities  of  departments  of  health  are 
conducted.  She  should  know  them  not  only  for  her  own  protec- 
tion but  in  order  that  she  may  direct  inquirers  to  the  proper 
sources  of  authority  and  infonnation.  The  work  of  a  public 
health  nurse  consists  largely  in  collecting  and  giving  informa- 
tion, and  she  must  be  able  to  point  to  a  specific  law,  regulation  or 
order  under  the  authority  of  which  her  acts  are  legalized;  m 
other  words,  she  must  know  exactly  what  can  be  done  legally  and 
what  can  not. 

The  legal  authority  for  most  acts  of  a  nurse  employed  or 
directed  by  the  State  Department  of  Health  is  derived  from  sec- 
tion 4  of  the  public  health  law  as  follows :  "  The  commissioner 
of  health  or  any  person  authorized  by  him  to  do  so,  may,  without 
fee  or  hindrance,  enter,  examine  and  survey  all  grounds,  erections, 
vehicles,  structures,  apartments,  buildings  and  places."  And 
again:  "He  (the  commissioner  of  health)  shall  make  inquiries 
in  respect  to  the  causes  of  disease,  especially  epidemics,  and  investi- 
gate the  sources  of  mortality,  and  the  effects  of  localities,  employ- 
ments, and  other  conditions  upon  health.  He  shall  obtain,  collect 
and  preserve  such  information  relating  to  mortality,  disease  and 
health  as  he  may  deem  useful  in  the  discharge  of  his  duty  or  may 
contribute  to  the  promotion  of  health  or  the  security  of  life  in  the 
state." 

A  supervising  nurse  employed  by  the  State  Department  of 
Health  is  assigned  to  a  particular  duty  and  her  powers  and 
responsibilities  are  limited  to  the  discharge  of  that  duty.  If  she 
meets  with  opposition  which  she  can  not  overcome,  she  is  expected 
to  communicate  with  the  State  Department  of  Health  at  once  and 
be  governed  by  the  instructions  given  her. 

A  nurse  employed  by  a  local  board  of  health  or  acting  under  its 
jurisdiction  is  the  representative  of  the  health  officer.  According 
to  section  26  of  the  public  health  law,  "  Every  such  board  shall 
receive  and  examine  into  all  complaints  made  by  any  inhabitants 
concerning  nuisances,  or  causes  of  danger  or  injury  to  life  and 
health  within  the  municipality,  and  may  enter  upon  or  within  any 
place  or  premises  where  nuisances  or  conditions  dangerous  to  life 
and  health  or  which  are  the  cause  of  nuisance  existing  elsewhere, 
are  known  or  believed  to  exist,  and  by  its  members  or  other  per- 
sons designated  for  that  purpose,  inspect  and  examine  the  same. 


12  State  Depart  mext  of  Health 

The  owners,  agents  and  occupants  of  any  such  premises  shall  per- 
mit such  sanitary  examinations  to  be  made." 

If  the  nurse  is  denied  entrance  to  any  premises,  or  if  she  is 
refused  any  information  requested,  the  facts  must  be  reported  to 
the  health  oflScer  who  then  takes  charge  of  the  matter. 

A  nurse  is  protected  against  acts  done  in  the  performance  of  her 
duty  by  section  21-b  of  the  public  health  law:  "No  health 
officer,  inspector,  jDublic  health  nurse,  or  other  representative  of  a 
public  health  officer,  and  no  person  or  persons  other  than  the  city, 
village  or  town  by  which  such  health  officer  or  representative 
thereof  is  employed,  shall  be  sued  or  held  to  liability  for  any  act 
done  or  omitted  by  any  such  health  officer  or  representative  of  a 
health  officer  in  good  faith  and  with  ordinary'  discretion  or  under 
the  direction  of  any  such  city,  village  or  town,  or  pursuant  to  its 
regulations  or  ordinances  of  the  sanitary  code  or  the  public  health 
laws." 

A  public  health  nurse  employed  by  a  society  has  official  stand- 
ing when  the  board  of  health  appoints  her  as  the  agent  of  the 
health  officer  and  enters  the  appointment  in  the  minutes  of  a 
regular  meeting. 

A  public  health  nurse  employed  by  the  board  of  managers  of  a 
county  tuberculosis  hospital  deals  primarily  wdth  tuberculosis 
cases,  and  if  opposed  in  an  investigation,  she  must  report  the  facts 
to  the  superintendent  of  the  hospital  or  to  the  proper  health 
officer. 

A  nurse  em])loyed  by  the  school  authorities  of  a  district  derives 
her  powers  from  the  department  of  education,  but  she  is  expected 
to  cooperate  with  the  board  of  health  in  matters  in  which  the 
jurisdiction  of  the  two  departments  overlap. 

Laws,  Regulations  and  Orders 
Public  health  nurses  and  all  other  officials  under  the  jurisdic- 
tion of  the  State  Department  of  Health  or  a  local  Ixjard  of  health, 
derive  their  authority  from  the  following  sources: 

(1)    Statutory  and  common  laws;  (2)  the  state  sanitary  code; 

(3)  orders  and  instructions  of  the  state  department  of  health; 

(4)  a  local  sanitary  code;  and  (5)  special  orders  of  a  local  board 
of  health. 


Public  Health  Nursing  13 

Statutory  laws  are  acts  passed  by  the  Legislature,  called  stat- 
utes. Examples  of  such  laws  are  the  public  health  laws,  the  vil- 
lage laws,  the  penal  code,  etc.  These  laws  are  grouped  together 
under  special  titles  and  numbered  by  articles  and  sections  in  order 
to  identify  them ;  as,  for  example,  section  21-c  of  the  public  health 
law,  giving  authority  for  the  employment  of  public  health  nurses. 

Common  laws  consist  mostly  of  interpretations  by  the  courts, 
eepecially  decisions  of  the  Court  of  Appeals,  which  decisions  have 
practically  the  force  of  statute  law  throughout  the  State.  They 
are  issued  in  volumes,  and  reference  to  a  decision  of  the  court  is 
made  by  giving  the  number  of  the  volume,  abbreviated  name  of 
the  State,  and  the  page;  as,  135  N.  Y.  390  (Vol.  135  of  the  New 
York  Reports  of  the  Court  of  Appeals,  page  390). 

The  sanitary  code  is  enacted  by  the  Public  Health  Council  of 
the  State  Department  of  Health,  by  authority  of  the  legislature 
giving  it  the  power  to  make  regulations  governing  all  matters 
which  affect  life  and  health.  The  sanitary  code  is  the  health 
officer's  guide,  and  must  often  be  consulted  by  the  public  health 
nurse.  The  sanitary  code  and  public  health  laws,  together  with 
special  regulations  issued  by  the  State  Commissioner  of  Health, 
are  published  by  the  State  Department  of  Health  in  a  book  entitled 
"  The  Public  Health  Manual,"  a  copy  of  which  is  a  necessary 
part  of  the  equipment  of  every  public  health  official  and  may  be 
obtained  free  upon  request.  A  nurse,  when  given  an  assignment, 
is  expected  to  familiarize  herself  with  the  laws  of  the  State  and 
the  regulations  of  the  sanitary  code  bearing  upon  her  work. 

Special  orders,  instructions  and  regulations  are  frequently 
issued  by  the  State  Commissioner  of  Health  under  the  authority 
conferred  by  the  public  health  law  and  the  sanitary  code,  and 
they  are  authoritative. 

Each  local  board  of  health  may  enact  regulations  upon  matters 
relating  to  public  health  in  the  municipality,  provided  that  the 
regulations  do  not  conflict  with  statute  laws  or  regulations  of 
the  state  sanitary  code.  These  regulations  constitute  the  local 
sanitary  code.  Each  community  is  granted  a  broad  measure  of 
home  rule  in  all  matters  pertaining  to  health  and  sanitation.  It 
may  increase  the  stringency  of  a  regulation  of  the  state  sanitary 
code,  and  may  enact  regulations  on  matters  not  mentioned  in  the 


14  State  Depautmext  of  Health 

state  code.  A  local  board  of  health  may  also  issue  a  special  order 
to  an  oifeuder  or  may  abate  an  insanitary  condition  which  is  not 
covered  by  the  sanitary  code  of  the  State  or  of  the  municipality. 
This  gives  the  local  l)oard  of  health  the  power  to  deal  with  cases 
in  an  emergency  or  with  new  problems.  A  nurse  who  works 
within  the  jurisdiction  of  a  local  board  of  health  is  therefore  ex- 
pected to  secure  copies  of  the  local  ordinances  and  special  orders. 

Relations 

Relation  to  health  officers.  Sections  4  and  21-b  of  the  public 
health  law  use  almost  identical  language  in  placing  the  responsi- 
bility for  enforcing  the  public  health  law  and  the  sanitary  code 
upon  the  Commissioner  of  Health  and  also  upon  the  health  offi- 
cers. The  State  Department  of  Health  has  assumed  the  principal 
part  of  the  Avork  in  some  activities,  such  as  the  supervision  of  mid- 
wives,  the  registration  of  births,  deaths  and  marriages,  and  the 
conducting  of  public  health  campaigns.  It  is  the  duty  of  the 
health  oiScer  to  supply  a  public  health  nurse  engaged  in  these 
activities  with  information,  and  to  assist  her  in  reaching  its 
sources. 

Other  activities,  such  as  the  suppression  of  epidemics  and  the 
abatement  of  nuisances,  belong  primarily  to  the  health  othcers. 
In  these  lines  of  work  a  public  health  nurse  acts  under  the  direc- 
tion of  the  local  health  officer. 

A  public  health  nurse  employed  by  a  board  of  health  is  subject 
to  the  direction  of  the  health  officer.  If  she  is  dissatisfied,  her 
appeal  is  first  to  the  health  officer  and  then  to  the  board  of  health. 

While  a  county  tuberculosis  nurse  is  not  under  the  authority  of 
any  health  officer,  yet  it  is  expected  that  she  will  work  in  coopera- 
tion with  the  local  health  officer  in  each  nmnicipality  and  any 
question  in  dispute  should  be  settled  by  the  superintendent  or  the 
board  of  managers  of  the  tuberculosis  hospital.  (Sw  also  Regula- 
tions, Laws  and  Agencies  relating  to  Tuberculosis  published  by 
State  Department  of  Health.) 

Relation  to  physicians.  A  public  health  nurse  can  be  of  great 
assi.stance  to  j)hysicians,  especially  in  connection  with  patients  who 
are  too  ]>oor  to  pay  or  are  too  ignorant  to  follow  directions.  She 
can  not  only  relieve  the  physicians  of  the  burden  of  explaining  the 


Public  Health  Xui^.slxg  15 

nature  of  disease  aud  the  methods  of  treatment  to  the  ignorant, 
but  she  can  persuade  the  careless  and  indifferent  to  persevere  in 
scientific  methods  of  treatment.  It  is  not  her  place  to  make  dis- 
tinctions between  physicians  but  extend  to  all  equal  courtesy 
and  resjject.  If  a  person  has  a  preference  for  any  particular 
physician,  it  is  the  duty  of  the  nurse  to  regard  that  prefer- 
ence. If  she  is  loyal  and  helpful  to  all  physicians  alike  she  has  a 
right  to  take  an  indigent  patient  in  need  of  medical  assistance  to 
the  physician  whom  the  patient  prefers  and  to  receive  free  advice 
as  to  the  condition  and  treatment  of  the  case. 

Relation  to  relief  organizations.  A  public  health  nurse  should 
cooperate  with  relief  officers  and  organizations,  such  as  overseers 
and  superintendents  of  the  poor,  societies  for  the  prevention  of 
cruelty  to  children,  and  for  the  prevention  of  blindness.  Red  Cross 
societies,  charitalile  organizations,  and  churches.  She  works  with 
all  these  agencies,  and  is  one  of  their  principal  representatives  in 
lines  of  work  affecting  the  health  of  persons  who  are  unable  to 
care  for  themselves.  8he  refers  cases  to  them,  and  secures  their 
assistance  in  her  own  health  work. 

Relation  to  the  public.  The  relation  of  a  public  health  nurse  to 
the  public  is  princi])ally  that  of  an  investigator,  adviser  and 
teacher.  Her  methods  are  those  of  persuasion  and  instruction 
rather  than  force.  It  is  not  within  the  scope  of  her  work  to  issue 
orders  or  to  make  threats  against  offenders.  If  legal  action  or 
force  is  necessary,  it  nmst  be  applied  ]>y  the  health  officer,  or  liy  the 
State  Commissioner  of  Health. 

Work  axd  Activities 

Assignments.  A  public  health  nurse  employed  by  the  depart- 
ment of  health  of  the  state  or  of  a  city  receives  from  time  to  time, 
usually  in  writing,  special  orders  or  assignments.  If  employed 
by  a  local  health  board  the  nurse  may  do  any  branch  of  public 
health  work  that  occasion  requires;  but  every  such  nurse  is  re- 
sponsible to  the  local  health  officer  from  whom  she  receives  her 
assignments  and  to  whom  she  is  expected  to  report  the  results  of 
her  work.  The  Avork  of  a  public  health  nurse  may  be  classified  as 
field  and  office  work. 

Field  ivorJc,     Field  notes,  taken  on  the  spot,  arc  an  iiidi:.'!)?!!- 


li)  State  Depakt^mext  of  Heat.th 

sable  part  of  all  field  work.  Eveiy  nurse  should  carry  a  note- 
book in  which  she  can  make  records  while  doing  her  work. 
In  investigating  an  outbreak  of  an  epidemic  of  measles,  scarlet 
fever  or  typhoid  fever,  for  example,  she  should  make  her 
records  at  each  house  or  place  that  she  visits  as  she  obtains  her 
information,  writing  down  the  names  and  addresses  of  the  cases 
and  contacts,  the  dates  of  onset  of  illness,  and  all  other  facts  or 
conditions  which  relate  to  the  epidemic.  This  is  absolutely  neces- 
sary, not  only  because  she  can  not  tnist  to  memory  for  such  details, 
but  because  the  notebook  is  positive  evidence  of  what  she  dis- 
covered by  her  investigation  and  will  l)e  accepted  as  such  in  law 
should  the  case  come  before  the  courts.  Elinor  items  which  would 
ordinarily  be  forgotten  if  not  recorded,  may  also  form  clues  which 
may  lead  to  further  important  information  or  serve  to  confirm 
other  facts,  and  if  these  are  set  do^vn  in  ■v\Titing  they  may  be 
studied  at  leisure. 

Office  luork.  The  routine  office  work  of  a  public  health  nurse 
will  usually  be  done  along  the  following  lines : 

(1)  Reviewing,  analyzing,  arranging  and  tabulating  her  field 
notes ; 

(2)  Formal  reports; 

(3)  Research  work  in  the  office  files  and  library; 

(4)  Correspondence; 

(5)  Reading  and  study. 

A  field  notebook  is  a  collection  of  items  recorded  in  the  order  in 
vv^hich  the  information  was  obtained,  without  regard  to  arrange- 
ment. The  notebook  is  intended  for  the  use  of  the  nurse  only,  and 
it  should  be  preserved  in  its  original  form  as  confirmative  evidence 
of  the  facts,  should  they  be  disputed:  Imt  the  items  require  to  be 
classified  and  arranged  in  such  manner  that  the  facts  which  they 
record  are  readily  availal)le  to  others.  To  do  this  will  take  time 
which  can  not  be  spared  in  the  field,  where  much  of  the  Avork  will 
be  done.     Ileuce  it  has  to  ho  completed  in  the  office. 

The  State  Department  of  ITenlth  requires  formal  reports  of  nil 
work'  dour  by  nurses  in  its  employ.  Similar  reports  shouki  be 
recniircd  of  nurses  employed  by  local  boards  of  health  or  by  private 
agencies.  Such  report  should  be  transmitted  through  tbe  local 
officer  of  the  board   of   healtli.     The   preparation   may   require 


Public  Health  Nursing  17 

more  time  than  the  field  work  which  it  represents.  The  report 
should  be  descriptive  and  statistical,  giving  a  surmnary  of  the  work 
done  with  its  various  items.  It  should  give  a  clear,  complete  and 
concise  review  of  the  situation.  It  may  begin  with  a  short  descrip- 
tion of  the  work  and  end  with  a  statistical  summary.  The  report 
must  mention  the  assignment  for  doing  the  work  and  from  whom 
it  was  received,  and  it  must  contain  sufficient  data  to  enable  the 
reader  to  understand  why,  when,  where  and  how  the  work  was 
done  and  the  reasons  for  doing  it.  If  previous  reports  of  the  same 
conditions  have  been  made  they  should  be  referred  to  in  such  a 
way  that  they  may  be  easily  identified.  If  an  assignment  of  work 
requires  several  days  to  complete,  a  report  of  the  progress  of  the 
work  must  be  made  daily.  These  daily  reports  may  be  so  made 
that  collectively  they  form  the  complete  report.  A  nurse's  work 
is  constructive,  not  destructive;  its  object  is  not  to  criticize  past 
mistakes  but  to  improve  future  health  conditions.  If  she  finds, 
therefore,  that  work  previously  done  by  another  is  faulty,  due  to 
icTioraiK-p  or  incompetence,  she  mav  report  this  to  the  Sta+o 
Department  of  Health,  but  she  should  avoid  all  local  fault-finding 
and  offer  advice  and  assistance  only  to  improve  the  conditions, 
without  personal  comment  of  any  kind. 

A  nurse  is  often  required  to  do  research  work  in  looking  up 
reports  of  work  similar  to  hers  and  in  reading  articles  on  the  sub- 
ject in  books  and  periodicals  in  order  that  she  may  coordinate  her 
report  with  that  of  other  workers  in  the  same  field.  Moreover, 
she  should  become  familiar  with  what  others  are  doing  in  her  line 
of  work  so  that,  when  written,  her  report  will  be  a  contribution  to 
existing  sanitarv^  information. 

A  public  health  nurse  is  expected  to  devote  some  time  to  reading 
and  study  on  all  subjects  relating  to  public  health,  on  general 
subjects  of  information  so  that  she  may  be  prepared  for  any 
assignment,  even  though  it  be  outside  of  her  particular  line 
of  work.  Opportunity  should  be  given  to  attend  conferences 
as  provided  for  by  law  and  special  schools  or  courses  of  in- 
stniction,  possibly  at  the  expense  of  the  municipality,  private 
organization  or  industry  by  which  she  is  employed  if  the  benefits 
derived  are  likely  to  be  commensurate  with  the  expense  involved. 


18  State  Department  of  Health 

A  State  Department  of  Health  nurse  -vvho  is  sent  to  a  city  or 
village  should  communicate  first  of  all  with  the  sanitary  super- 
visor of  the  district,  and  with  the  local  health  officer.  She  should 
always  do  this  even  when  assistance  is  not  required.  The  sanitaiy 
supervisor  and  local  henltli  officer  are  entitled  to  ho  infomied  con- 
cerning ever^^  health  activity  in  their  district.  The  nurse  and  the 
lo.cal  officials  can  always  be  of  mutual  assistance  to  each  other 
and  recognition  of  this  fact  will  promote  goodwill  and  cooperation. 

A  public  health  nurse  is  expected  to  be  able  to  conduct 
her  own  investigations  independent  of  direct  assistance ;  she 
is  not  supposed  to  be  dependent  upon  any  local  official  for 
material  assistance,  transportation,  or  other  personal  help. 
If  it  is  necessary  to  give  a  nurse  assistance  the  assigning  officer 
will  arrange  for  the  specific  assistance  to  be  given.  At  the  same 
time  it  is  the  duty  of  every  local  health  officer  or  i-egistrar  to 
allow  the  nurse  access  to  his  official  records  and  to  give  her  any 
official  information  that  she  may  require. 

Expenses.  A  public  health  nurse  should  be  allowed  necessars' 
traveling  and  hotel  expenses  while  doing  field  work.  She  should 
be  expected  to  use  the  ordinary  public  conveyances  such  as  rail- 
roads, trolleys,  bus  lines  and  steamboats  whenever  possible  and 
not  to  hire  special  conveyances  unless  no  public  conveyance  is 
available.  When  unusual  expense  is  incurred,  she  should  obtain 
a  receipt  for  it. 

Hours  of  duly.  A  public  health  nurse  should  be  on  duty  from 
9  o'clock  A.  iM.  to  5  V.  M.,  with  an  hour  for  lunch.  If  she  is  doing 
field  work  her  hours  will  be  irregular  according  to  the  character 
of  her  work.  She  may  have  to  work  all  day  and  in  the  evening, 
as  in  securing  cultures  and  specimens.  She  should  devote  sufficient 
time  to  the  work  in  hand  to  accomplish  it  efficiently  and  ]>roin])tly. 
A  ])ublic  health  nurse  should  not  be  expected  to  work  on  Sunday 
idthough  in  an  emergency  she  may  he  nniuired  to  do  so. 

Lines  of  work.  The  three  great  divisions  of  work  in  which 
public  health  nurses  and  all  pu1>lic  h(\',lth  officials  are  engaged  are: 
J    (1)    Sanitation; 

(2)    Control  of  communicable  diseases;  and 


Public  Health  Nursing  19 

C^  (3)   General  measures  for  the  improvement  of  health  and  the 
prevention  of  disease. 

Sanitation.  Sanitation  is  concerned  with  the  environment  of 
man  and  deals  with  the  physical  conditions  outside  of  the  l>ody 
aifecting  the  puhlic  health,  rather  than  with  the  individual  him- 
self, which  constitutes  personal  hygiene.  Sanitation  is  the 
peculiar  field  of  work  of  the  sanitary  engineer  or  inspector,  and 
not  of  the  health  physician  or  nurse;  but  when  no  sanitary 
inspector  is  available,  the  public  health  nurse  may  be  called  upon 
to  assist  a  health  officer  in  making  the  annual  sanitaiy  survey  of  a 
district,  as  required  by  section  21-b  of  the  public  health  law,  or 
she  may  be  assigned  to  make  a  formal  sanitary  inspection. 

This  survey  or  inspection  should  take  cog-nizance  of  and  includtJ 
a  report  on  the  sanitary  conditions  of  all  buildings  and  premises, 
public  or  private,  where  a  menace  to  health  may  exist ;  and  super- 
vision must  be  maintained  to  prevent  the  recurrence  of  insanitary 
conditions. 

The  follo\^iiig  conditions  are  to  be  specially  investigated: 
^(1)   Food  sanitation,  including  the  milk  supply  and  food  sup- 
plies other  than  milk,  to  insure  pure  food  supplies  and  the  pre- 
vention of  insanitary  methods  of  handling; 

"  (2)  Water  supplies,  to  insure  pure  supplies  of  water  and  the 
prevention  of  careless  disposal  of  human  excrement ; 

(3)  Sewage  and  waste  disposal;  and 

(4)  Breeding  places  for  flies,  mosquitoes  and  other  insects  and 
vermin. 

Control  of  communicahle  diseases.  The  control  of  communi- 
cable diseases  is  related  to  man  himself,  and  the  disease  germs 
Avhich  grow  within  the  human  body  far  more  than  with  man's 
environment. 

For  supervision  in  the  control  of  communicable  diseases  the 
public  health  nurse  may  be  assigned  to  any  or  all  of  the  following 
lines  of  w^ork: 

''(1)    Investigation  of  the  modes  and  channels  of  infection; 
V  (2)   Discovery  of  unrecognized  or  unreported  cases; 
-  (3)   Instruction  of  the  public  in  measures  to  prevent  further 
spread  of  infection; 


20  State  Department  of  Health 

•  (4)   Securing   laboratory   specimens   for   diagnostic   purposes; 
v/  (5)   Supervision  of  quarantine; 

(6)  Cooperation  of  school  and  health  authorities  in  the  control 
of  communicable  diseases; 

(7)  Cooperation  with  various  charitable  organizations  for 
adequate  hospital  care  of  the  sick  and 

(8)  Cooperation  with  other  philanthropic  agencies  for  pre- 
vention of  needless  distress  in  families  under  quarantine  or  other- 
wise disabled  (as  in  tuberculosis)  by  the  presence  of  disease. 

In  milking  investigations  for  the  discovery  of  unreported  cases 
the  nurse  may  be  required  to  prepare  maps  and  charts  to  illustrate 
the  facts  in  graphic  form.  She  may  also  be  requested  to  furnish 
material  for  the  press  in  order  to  arouse  public  sentiment  and  thus 
assist  in  controlling  the  situation.     ^ 

General  measures.  Eveiry  constructive  program  for  the  improve- 
ment of  health  and  the  prevention  of  disease  should  be  preceded 
by  a  preliminary  study  of  the  conditions  present  in  a  community 
which  are  inimical  to  health.  For  example,  it  would  be  obviously 
unnecessary  to  do  extensive  educational  work  for  the  reduction  of 
infant  mortality  in  a  community  which  has  a  low  infant  death 
rate,  or  to  devote  much  time  and  labor  to  propaganda  for  the 
prevention  of  tuberculosis  in  a  district  where  comparatively  few 
cases  of  this  disease  occur.  Local  conditions  studied  in  advance 
must  determine  what  work  is  needed.  One  may  often  learn  from 
reports  of  other  communities  how  certain  results  have  been  accom- 
plished. Communities,  however,  have  their  individualities  just  as 
persons  have,  and  it  is  not  always  practicable  to  employ  in  one 
community  the  methods  which  have  proved  successful  in  another. 
Each  community  must  be  studied  by  itself. 

General  measures  for  the  improvement  of  health  and  the  pre- 
vention of  disease  will  include  the  following  lines  of  work: 

(1)  Public  health  education; 

(2)  The  study  of    vital  statistics  records; 
■73)   Infant  welfare  activities; 

(4)   Supervision  of  midwives; 


Public  Health  Nuesing  21 

(5)  Control  of  commiinicahle  disease,   including  tuberculosis 
and  venereal  disease; 

(6)  Health  supei-vision  of  the  school  child  ; 

(7)  Hygiene  of  home  and  workshop;  and 

(8)  Mental    hygiene  —  prevention    of    insanity    and    mental 
defects. 


State  Department  of  Health 


CHAPTER  H 
Sanitary  Inspection 

The  public  health  nurse,  in  making  a  sanitary  survey  of  a  dis- 
trict, should  carefully  ohsen^e  the  surroundings  of  every  locality 
which  she  visits,  whether  it  be  for  the  control  of  communicable 
disease,  for  the  promotion  of  child  welfare,  or  for  some  other  pur- 
pose. She  may  also  be  assigned  to  the  work  of  making  a  formal 
sanitary  inspection. 

Dryness,  sunlight  and  cleanliness  are  the  keynotes  of  sanitation 
in  the  modern  acceptation  of  the  term.  We  now  know  that  most 
disease  germs  do  not  grow  and  multiply  in  such  environment.  ]^ot 
all  conditions  which  appear  dirty  or  unsightly  are  necessarily 
dangerous  to  health,  but  on  the  other  hand,  apparently  clean  and 
sightly  surroundings  may  not  be  sanitaiy.  Almost  all  of  the  com- 
municable diseases  are  contracted  through  close  personal  contact 
with  human  beings,  the  greatest  enemy  to  mankind  1)cing  man 
himself. 

The  chief  importance  of  insanitary  conditions  due  to  the  lower 
animals,  to  decaying  vegetables  and  to  dirt  from  inanimate 
sources,  is  that  they  may  permit  the  breeding  of  flies,  and  other 
insects  and  vei-inin  which  may  be  the  means  of  transmitting  dis- 
ease germs  of  human  origin  and  so  indirectly  cause  the  spread  of 
infection.  Most  of  the  diseases  of  man,  especially  those  which 
occur  in  epidemic  form,  are  peculiar  to  human  beings.  Some  of 
these  infections  may  be  communicated  to  the  lower  animals  under 
experimental  conditions,  but  they  do  not  occur  in  them  as  a  nile 
under  natural  conditions.  Fonnerly  sanitarians  regarded  the 
environment  as  the  main  source  of  infection  ;  but  it  has  been  found 
by  experience  that  though  this  may  be  the  modiuin  of  conveyance 
of  disease  it  is  not  the  source  of  infection.  Wlicn  a  nurse  mjikcs 
a  sanitary  inspection,  therefore,  she  iiuisl  look  especially  for  con- 
ditions which  are  of  human  origin. 

The  danger  to  health  from  human  excretions  arises  fi"om  the 


Public  Heat.th  Nursing  23 

fact  that  disease  gemis  may  be  present  in  them.  All  human 
bein^jjs  do  not  give  off  infectious  organisms  but  only  sick  people 
or  disease  carriers ;  the  latter  are  persons  who  harbox  germs  of  a 
certain  disease  without  showing  symptoms  of  it.  Those  who  dis- 
charge disease  germs  constitute  but  a  small  proportion  of  the 
population.  Many  persons  excrete  these  germs  without  knowing 
it  and  take  no  care  of  their  excretions.  For  this  reason  it  is  ex- 
ti'emely  difficult  to  control  disease  carriers.  Any  collection  of 
human  excretions  may  contain  disease  germs  from  an  unsuspected 
sourse  and  therefore  should  be  considered  as  suspicious  or  dan- 
gerous however  small  the  amount.  Millions  of  disease  germs 
may  be  present  in  an  infinitesimal  quantity  of  excretion  deposited 
on  soiled  hands.  Even  a  single  typhoid  bacillus  in  milk  may 
cause  an  epidemic,  while  a  drop  of  intestinal  excretion  from  a 
typhoid  carrier  may  infect  a  household  water  supply. 

Insanitary  conditions  which  produce  disease  may  be  few  in  a 
given  community,  but  efforts  should  be  made  to  abate  all  such 
conditions.  One  of  the  chief  factors  in  increasing  the  danger 
from  insanitary  conditions  is  congestion  of  population.  A  single 
family  living  in  the  country,  separated  widely  from  other  people 
and  seldom  receiving  visitors,  nins  little  chance  of  disease  infec- 
tion, but  if  there  are  a  hundred  or  more  families  in  a  group,  or  if 
a  large  number  of  persons  are  crowded  upon  a  small  area  and  the 
families  live  in  cramped  dwelling  quarters,  congestion  favors  the 
transmission  of  disease,  especially  if  it  is  associated  with  poverty, 
ignorance,  uncleanliness  and  low  standards  of  living.  Insanitary 
conditions,  therefore,  which  may  be  comparatively  harmless  at  an 
isolated  farmhouse,  become  an  actual  menace  to  health  in  a  village 
or  city.  As  population  increases  the  importance  of  sanitation 
grows  at  a  relatively  much  more  rapid  rate.  Urban  or  concen- 
trated populations  present  far  greater  sanitaiy  problems  than 
rural  scattered  populations. 

Insanitary  surroundings  affect  health  in  direct  proportion  to  the 
opportunity  for  contaminated  substances  to  enter  the  body. 
The  principal  agents  for  the  transmission  of  contaminated  sub- 
stances are:  (1)  persons,  by  coming  in  contact  with  such  sub- 
stances; (2)  food;  (3)  flies;  (4)  drinking  water. 


24  State  Department  of  Health 

Persons  may  transmit  contamination  from  their  hands,  clothing 
and  from  various  articles  to  other  persons  by  personal  contact, 
i^'ood  and  water  even  slightly  contaminated  are  likely  to  produce 
disease  because  they  are  taken  into  the  body  in  considerable  quan- 
tity where  the  conditions  are  favorable  for  the  growth  and  multi- 
plication of  the  disease  genns.  House  flies  breed  in  horse  manure 
and  human  excrement  and  in  fermented  and  putrefying  vegetable 
matter,  and  they  may  contaminate  food  supplies  by  acting  as 
mechanical  carriers  of  infection.  Decaying  and  putrefying 
vegetable  matter,  though  offensive  to  the  senses,  is  not  necessarily 
dangerous  unless  it  contains  disease  germs  deposited  in  it  from 
human  sources.  Decaying  substances  do  not  in  themselves  cause 
disease,  although  indirectly  they  may  affect  health  by  forming 
breeding  places  for  flies. 

If  a  nurse  is  asked  to  make  a  sanitary  inspection  of  occupied 
houses  and  premises  she  should  begin  by  asking  the  owner,  agent 
or  occupant  of  the  premises  to  accompany  her  or  to  give  her  per- 
mission to  make  the  inspection.  Although  a  health  department 
nurse  has  a  legal  right  to,  inspect  insanitaiy  premises  she  should 
use  diplomacy  and  tact  rather  than  legal  authority  to  achieve  her 
object.  If  she  is  refused  admission  the  fact  should  be  reported 
immediately  to  her  superior  officer,  but  as  a  rule  the  nurse  will 
be  well  received.  She  should  confine  her  inspection  strictly  to  the 
work  in  hand,  the  sanitary  conditions  which  caused  her  inspection 
of  private  property,  and  make  no  comments  about  other  matters. 

Conditions  which  a  nurse  is  ordinarily  requested  to  ob- 
serve arc:  (1)  general  topography;  (2)  housing;  (3)  cleanli- 
ness; (4)  household  drainage;  (5)  disposal  of  human  excrement; 
(6)  garbage  disposal;  (7)  barnyard  conditions;  (8)  breeding 
places  of  flies,  mosquitoes,  etc.;  (9)  water  supply;  (10)  milk 
supply;  and  (11)  food  handling.  These  are  the  most  important 
conditions  directly  affecting  health,  though  there  are  many  others 
having  little  or  no  effect  upon  health  which  may  be  classed  as 
nuisances  and  which  are  under  the  control  of  the  department  of 
health  and  also  within  the  scope  of  inquiry  by  the  sanitary 
inspector  or  nurse. 

General  topography.  This  includes  relation  and  reference  to 
wells,  bodies  of  water,  woods,  housas  and  other  features  of  the 


Public  Health  Nursing  25 

locality.  The  most  important  thing  for  the  public  health  nurse  to 
note  is  the  soil  in  relation  to  household  drainage;  the  slope  of  the 
ground  surface  in  order  to  deteniiine  the  direction  of  the  flow ; 
the  nature  of  the  soil,  whether  rocky,  clayey  or  sandy,  in  order  to 
observe  its  capacity  to  absoi-b  and  conduct  the  drainage ;  and  the 
character  of  the  subsoil  from  which  the  private  water  supply  is 
drawn. 

Housing.  The  next  point  to  observe  is  the  house  in  relation  to 
the  size  of  its  living  quarters  and  the  number  of  persons  occupying 
a  room,  in  order  to  determine  whether  it  is  overcrowded  or  inade- 
quately ventilated.  In  connection  with  housing  are  to  be  con- 
sidered such  conditions  as  darkness,  dampness,  cold  and  uncleanli- 
ness.  Darkness  is  usually  associated  with  dirt  and  dampness.  A 
lack  of  sufficient  windows  will  affect  health.  A  house  that  is  out  of 
repair  is  often  an  indication  of  a  low  standard  of  living.  The 
sensation  of  warmth  or  coldness  will  be  a  rough  guide  as  to  the 
temperature  of  a  room,  and  the  odor  of  the  indoor  air  as  to  ventila- 
tion. Ventilation  and  heating  are  important  factors  in  housing; 
and  will  be  discussed  later. 

Cleanliness.  Cleanliness  is  the  comer  stone  of  sanitation. 
Cleanliness  of  rooms,  furnishings  and  persons  are  most  important 
points  to  observe  in  making  a  sanitary  inspection.  The  sanitarian's 
conception  of  cleanliness  of  surroundings  has  greatly  changed  with 
the  advance  of  knowledge  as  to  the  kinds  of  dirt,  the  degrees  of 
dirtiness  and  the  nature  of  these  in  relation  to  health.  The 
modern  standard  of  cleanliness  is  not  physical  or  esthetic,  but 
biological.  The  infection  on  household  utensils  or  in  water, 
milk,  food  or  on  other  objects  can  not  be  seen,  although  the  danger 
of  such  invisible  dirt  is  known.  It  requires  a  bacteriologist  to 
tell  the  difference  between  dean  dirt  and  insanitary  dirt.  We 
must  therefore  insist  upon  scrupulous  cleanliness  and  educate 
people  to  understand  the  biological  meaning  of  this  tei-m.  Experi- 
ence has  taught  that  cleanliness  is  the  most  efficient  single  means 
that  we  possess  for  protection  against  disease ;  that  clean  surround- 
ings are  apt  to  be  free  of  infection;  that  olean  food  is  apt  to  be 
safe  food.  This  practically  means  that  only  dirt  which  is  con- 
taminated with  disease  germs  is  dangerous  to  health.  House  dirt 
may  contain  disease  organisms,  especially  that  which  has  been 


26  State  Department  of  Health 

recently  contaminated  with  human  discharges.  Drying  usually 
kills  most  disease  germs  within  a  few  hours,  but  the  germs  may  be 
alive  for  some  time  in  dust  containing  freshly  dried  excre- 
tions. Few  bacteria  will  survive  vigorous  washing  and  cleansing 
such  as  a  cleanly  and  careful  housewife  gives  to  her  rooms  and 
furniture.  The  public  health  nurse  should  therefor  carry  on  a 
campaign  for  sanitaiy  cleanliness  just  as  the  surgeon  does  for 
surgical  cleanliness. 

Household  drainage.  The  drainage  from  a  household  is  an 
important  item  in  every  sanitary  inspection.  If  the  waste  water 
is  conducted  into  a  sewer  the  nurse  should  obser\'e  only  the  clean- 
liness of  the  plumbing,  and  take  note  of  any  suspicious  leakage. 
If  the  house  has  plumbing  which  is  connected  with  a  cesspool  she 
should  inspect  the  latter  to  see  whether  it  is  properly  covered 
and  not  overflowing.  If  the  house  has  no  plumbing  she  should 
observe  whether  or  not  the  waste  water  from  the  kitchen  and 
laundi-y  is  allowed  to  accumulate  in  pools  near  the  house.  Many 
houses  in  the  country  lack  proper  facilities  for  house  drainage. 

The  methods  of  disposal  of  household  drainage  are  discussed  in 
the  chapter  on  the  disposal  of  sewage  (page  66). 

Disposal  of  human  excrement.  One  of  the  most  important 
items  of  sanitary  inspection  is  the  manner  of  disposal  of  human 
excreta.  Particular  note  should  be  made  as  to  the  possibility  of 
contamination  of  the  water  supply  and  as  to  the  means  taken  to 
prevent  the  access  of  flies. 

The  methods  of  disposal  of  human  excrement  are  discussed  in 
the  chapter  on  the  disposal  of  sewage  (page  66.) 

Garbage  disposal.  Garbage  consists  of  waste  foods  from  the 
kitchen  iiiul  dining  room;  it  is  often  mixed  with  paper  waste, 
tin  cans,  etc.  It  seldom  contains  disease  germs  or  is  a  direct 
menace  to  health.  It  is  importajit,  however,  to  the  sanitarian 
because  it  readily  undergoes  fermentation  and  putrefaction ;  and 
because  it  mny  be  the  breeding  place  for  flies  and  may  attract 
vermin. 

The  common  methods  of  garbage  disposal  are:  (1)  feeding 
it  to  fowls  and  pigs,  which  is  an  economical  method  and  more 
sanitai-y  thnn  if  it  were  left  to  decay;  (2)  burial,  either  in  the 
ground  or  in  ;i  manure  pile,  which  is  a  sanitary  method  if  the 


Public  Health  Nursing  27 

garbage  is  covered  to  a  depth  sufficient  to  place  it  out  of  reach  of 
flies;  (3)  incineration,  which  is  the  most  sanitary  of  all  methods 
when  properly  done;  (4)  reduction,  or  the  recovery  of  fats  and 
fertilizer  which  in  some  city  garbage  works  pays  for  the  collection. 

In  noting  the  methods  of  garbage  disposal  the  following  con- 
ditions are  to  be  reported  by  a  public  health  nurse  as  unsatis- 
factory: (1)  garbage  heaps  in  the  back  yard ;  (2)  flies  or  fly  larvae 
in  the  garbage;  {?>)  garbage  containers  out  of  repair,  or  not  prop- 
erly cleaned;  (4)  absence  of  tight  covers  on  the  containers. 

Barnyard  conditions.  Barnyards  come  under  the  supervision 
of  health  officials  only  in  so  far  as  they  directly  or  indirectly  atfect 
health.  In  this  sense  they  may  be  the  breeding  places  for  flies  and 
mosquitoes,  etc. ;  they  may  hinder  the  production  of  pure  milk ; 
they  may  be  sources  of  water  pollution ;  and  they  may  become  har- 
boring places  for  rats  and  other  vermin.  They  are  not  considered 
as  direct  sources  of  infection  unless  they  are  polluted  with  human 
excretions,  but  they  may  be  contributory  causes  of  disease  and 
thus  should  be  controlled  by  the  health  department. 

Fly  control.  A  nurse  who  is  making  sanitary  inspections  should 
look  for  the  breeding  places  of  flies,  especially  during  the  summer 
months.  These  are  usually  found  in  manure  piles,  garbage  heaps, 
stables,  privies  and  other  places  in  which  decaying  vegetable  or 
animal  mattei  is  deposited.  Methods  of  fly  control  include  the 
use  of  covered  containers  to  prevent  the  access  of  flies  to  breeding 
places;  the  use  of  chemicals  to  destroy  fly  larvae  and  pupae  in 
manure  piles ;  and  mechanical  methods  of  protection  from  flies, 
such  as  screening  traps,  fly  paper,  etc. 

The  subject  of  fly  control  is  discussed  in  the  chapter  on  breeding 
places  for  flies  and  other  insects  (page  87). 

Mosquito  extermination.  ]\Iosquitoes  breed  in  almost  any  col- 
lection of  stagnant  water,  even  though  it  be  only  a  cupful  or  leas. 
The  discovery  that  certain  kinds  of  mosquitoes  are  necessar)^  to 
the  completion  of  the  life  cycle  of  the  organisms  of  malaria  and 
yellow  fever  has  made  the  control  of  their  breeding  places  of  great 
importance  in  localities  where  these  diseases  are  prevalent.  The 
annoyance  caused  by  other  kinds  of  mosquitoes  which  are  not 
known  to  be  disease  carriers  makes  their  extinction  also  very 
desirable.  The  same  measures  of  extermination  are  effective 
against  all  varieties  of  mosquitoes.     One  of  the  most  important 


28  State  Department  of  Health 

of  these  measures  is  the  control  of  house  drainage  and  rain  water 
near  dwellings.  Any  untreated  <3ollection  of  stagnant  water  in 
the  summer  time  should  ]ye  condemned  on  the  ground  that  it  may 
breed  mosquitoes. 

The  subject  of  mosquito  extermination  is  discussed  in  chapter 
VI  (page  89). 

Water  supply.  The  source  and  character  of  the  water  supply 
is  one  of  the  most  important  items  of  sanitary  inspection.  A 
nurse  should  first  inquire  whether  the  supply  is  derived  from  a 
public  or  private  source;  if  it  is  from  a  lake,  stream,  spring,  open 
or  driven  well,  or  cistera.  The  character  of  the  water  may  be 
best  judged  by  an  analysis  of  a  sample  and  inspection  of  the  sur- 
roundings and  source.  If  there  is  evidence  of  contamination  the 
well  should  be  abandoned  or  the  water  from  it  boiled  except  that 
used  for  mechanical  purposes.  Public  water  supplies  are  under 
the  control  of  the  Division  of  Sanitaiy  Engineering  of  the  State 
Department  of  Health  and  their  supervision  is  largely  a  technical 
problem,  but  a  public  health  nurse  may  be  required  to  assist  in  a 
sanitary  inspection. 

The  elementary  principles  involved  in  securing  and  maintaining 
a  pure  water  supply  are  discussed  in  chapter  IV  (page  50). 

ilftZA:  supply.  The  principal  conditions  pertaining  to  milk 
which  affect  health  are:  (1)  the  health  of  the  cow;  (2)  the 
presence  of  barnyard  dirt  which  may  enter  the  milk;  (3)  the 
changes  which  the  milk  usually  undergoes ;  and  (4)  human  disease 
germs,  which  may  be  introduced  into  the  milk  by  the  insanitary 
methods  of  those  who  handle  it. 

From  a  sanitary  standpoint  the  modern  circumstances  which 
tend  to  increase  the  danger  from  milk  are:  (1)  large  routes  of 
collection  and  delivery  by  means  of  which  an  infection  at  any  one 
dairy  is  spread  through  a  distributing  center  to  a  great  number  of 
customers;  (2)  long  periods  of  storage  and  transportation  by 
which  the  age  of  milk  before  delivery  is  increased;  (3)  the  larger 
number  of  persons  who  take  part  in  handling  it;  (4)  the  custom 
of  distributing  milk  in  bottles  which  are  collected  after  exposure  to 
contamination  in  the  household  and  the  resultant  work  and  care 
necessary  in  the  cleaning  of  the  bottles. 

To  meet  and  solve  the  different  problems  of  milk  production 


Public  Health  Nursing  29 

under  these  circumstances  requires  official  supervision,  and  in 
addition  the  kind  of  popuhir  education  which  a  public  health  nurse 
is  well  fitted  to  give,  A  public  health  nurse  may  also  be  required 
at  times  to  assist  in  inspecting  aaid  scoring  a  dairy. 

The  sanitary  principles  involved  in  securing  and  maintaining  a 
pure  milk  supply  are  discussed  in  chapter  III  (page  38). 

Food  handling.  A  public  health  nurse  may  be  called  upon  to 
inspect  the  methods  of  handling  and  storing  food  in  houses, 
bakeries  and  at  soda  fountains,  restaurants,  markets,  and  other 
places  where  food  is  prepared  and  handled  or  sold. 

Food  may  become  contaminated  during  handling  either  &om  its 
environment  or  from  the  handlers  themselves,  the  latter  way  being 
much  more  common.  The  principal  points  to  be  observed  in  the 
environment  of  food  are:  (1)  the  cleanliness  of  the  room  and  con- 
tainers; (2)  the  exposure  of  the  food  to  flies  and  dust;  and  (3)  the 
temperature  at  which  the  food  is  kept.  The  main  points  to  be 
noted  in  persons  who  handle  food  are :  (1)  cleanliness  of  hands  and 
clothing;  (2)  health,  especially  as  to  the  existence  of  colds,  coughs, 
sore  throat,  diarrhea  and  other  communicable  diseases;  and  (3) 
possibility  of  the  presence  of  healthy  carriers  of  disease.  The 
latter  are  usually  impossible  to  detect  without  a  systematic 
search  being  conducted  by  trained  health  officials  and  laboratory 
tests  made  on  specimens  of  discharges  obtained  from  such  sus- 
pected persons.  A  nurse  should  also  observe  whether  food  is  to 
be  eaten  raw  or  cooked,  as  raw  food  is  always  to  be  considered 
dangerous  if  handled  by  unclean  persons  or  in  unclean  surround- 
ings. The  heat  of  cooking  usually  destroys  both  disease  germs 
and  the  bacteria  of  fermentation  and  decay.  The  nurse  should 
not  be  deceived,  however,  by  the  cleanliness  of  the  dining  room 
or  the  attractiveness  of  the  food  on  the  table,  but  she  should  judge 
of  the  sanitary  condition  of  the  food  in  the  storeroom  and  kitchen 
before  it  is  cooked.  Unclean  cooks  and  kitchen  equipment  may 
infect  food  with  disease  germs  which  give  no  indication  of  their 
presence. 

The  chief  points  to  be  observed  in  food  handling  in  homes  are: 
(1)  general  cleanliness  of  the  kitchen,  pantry  and  containers,  and 
of  persons  who  handle  the  food;  (2)  presence  of  flies  on  food  and 
of  vermin  in  the  kitchen  and  pantry;  (3)  temperature  at  which 
food  is  kept. 


30  State  Department  of  Health 

Places  of  Public  Assemblage  Where  Food  is  Prepared, 
Hai^^dled  and  Sold 

The  handling  of  food  is  forbidden  in  certain  cases  by  the  State 
Sanitary  Code  (Chapter  II,  Eeguhition  39),  as  follows:  "I^To  per- 
sons affected  with  any  communicable  disease  shall  handle  food  or 
food  products  intended  for  sale  which  are  likely  to  be  consumed 
raw  or  liable  to  convey  infective  material,  No  person  who  resides, 
boards  or  lodges  in  a  household  where  he  comes  in  contact  with  any 
person  affected  with  the  bacillary  dysentery,  diphtheria,  epidemic 
or  septic  sore  throat,  measles,  paratyphoid  fever,  scarlet  fever, 
poliomyelitis,  acute  anterior  (infantile  paralysis),  or  typhoid 
fever,  shall  handle  food  or  food  products  intended  for  sale.  No 
waiter,  waitress,  cook  or  other  employee  of  a  boarding  house,  hotel, 
restaurant,  or  other  place  where  food  is  served,  who  is 
affected  with  any  communicable  disease,  shall  prepare,  serve 
or  handle  food  for  others  in  any  maimer  whatsoever.  No  waiter, 
waitress,  cook,  or  other  employee  of  a  boarding  house,  hotel, 
restaurant,  or  other  place  where  food  is  served,  who  lodges  or 
visits  in  a  household  where  he  comes  in  contact  with  any  person 
affected  with  bacillary  dysentery,  diphtheria,  epidemic  or  septic 
sore  throat,  measles,  paratyphoid  fever,  scarlet  fever,  poliomyelitis, 
acute  anterior  (infantile  paralysis),  or  typhoid  fever  shall  pre- 
pare, serve  or  handle  food  for  others  in  any  manner  whatsoever."' 

Since  it  is  not  practically  possible  to  insure  that  employees  in 
establishments  where  food  is  prepared,  handled  or  sold  are  not 
carriers  of  disease,  inspection  here  is  the  only  safeguard  against 
infection. 

During  an  epidemic  or  at  any  time  that  he  sees  fit,  the  health 
officer  may  detail  the  public  health  nurse  to  routine  inspection  of 
bakeries,  soda-water  fountains,  restaurants,  markets,  and  other 
places  of  public  assemblage  where  food  is  prepared,  handled  or 
sold. 

In  making  an  inspection  of  an  eating  house  the  nurse  should 
note  the  date,  street,  number,  name  of  o^vner  and  proprietor, 
address  and  business;  whether  foods  are  exposed  to  flies  and  other 
insects,  dust  or  dirt ;  whether  the  clothing  of  persons  handling  food 
is  clean;  and  whether  the  business  is  conducted,  in  a  cleanly 
manner,  especially  as  to  the  methods  and  thoroughness  of  dish 
washing,  and  should  give  details.   She  should  note  the  constniction 


Public  Health  Nursing  31 

of  the  place  where  foods  are  sold  or  stored ;  if  water-closet  and 
lavatory  are  provided ;  if  they  are  separate  from  the  room  where 
foods  are  sold  or  stored,  and  their  condition ;  if  cuspidors  are  pro- 
vided and  their  condition,  whether  disinfectants  are  used ;  and  if 
the  store  or  storeroom  is  used  as  a  dormitory.  She  should  inquire 
as  to  the  health  of  persons  handling  food ;  if  they  are  in  good 
health  themselves ;  if  there  is  any  illness  in  their  families ;  if  there 
are  cases  of  illness  in  persons  who  have  been  living  or  working  on 
the  premises  but  who  have  departed,  their  names,  addresses  and 
means  of  identification,  and  the  extent  of  their  contact  with  other 
persons  to  whom  they  might  communicate  the  disease.  When  the 
facts  point  to  infection  of  any  particular  place,  the  homes  of  cooks, 
waitresses  and  other  employees  should  be  visited. 

If  the  disease  may  be  water-borne  and  the  mode  of  infection  has 
not  been  determined,  the  source  of  the  water  supplies  should 
receive  special  attention,  and  in  the  case  of  a  spring  or  well  it 
should  be  inspected  in  order  to  discover  whether  it  is  liable  to 
become  contaminated.  If  bottled  water  is  used  the  brand  should 
be  noted,  and  if  communicable  disease  is  present  on  the  premises, 
whether  the  empty  bottles  are  returned  to  the  dealer,  and  what,  if 
any,  measures  are  taken  to  prevent  possible  spread  of  infection. 
The  presence  of  dogs  and  cats,  with  possible  opportunity  to  convey 
infection,  should  receive  attention  and  record. 

If  the  disease  may  possibly  be  milk-borne  the  fullest  details 
should  be  given  concerning  the  source  of  the  milk  supply  of  both 
milk  and  ice  cream,  and  the  care  of  the  milk  and  empty  con- 
tainers used  on  the  place.  When  communicable  disease  is  present 
milk  and  ice  cream  containers  must  be  sterilized  by  methods 
approved  by  the  health  officer  before  they  are  returned.  When 
laboratory  specimens  are  desired  the  nurse  will  be  required  to 
secure  these  during  her  visit  and  forward  them  at  once  to  the 
laboratory,  together  with  a  detailed  report  (on  a  blank  form  fur- 
nished by  the  State  Department  of  Health)  containing  specific 
information  collected  during  the  investigation. 

The  instructions  she  gives  should  include  suggestions  regarding 
desirable  changes  to  be  made  in  methods  and  conditions,  and  the 
place  should  be  subsequently  inspected,  when  necessary,  to  see 
whether  these  conditions  have  been   corrected.     Revisits  should 


32  State  Department  of  Health 

follow  promptly  when  insanitary  conditions  are  found,  and  be  con- 
tinued at  frequent  intervals  until  they  are  found  to  be  remedied. 
Persistence,  tact  and  courtesy  will  remedy  a  large  majority  of 
insanitary  conditions  without  resort  to  compulsion. 

In  ijispection  of  bakeries  imd  confectioneries  the  above  prin- 
ciples should  be  carried  out,  special  attention  being  paid  to  cleanli- 
ness of  habits  and  methods  on  the  part  of  operators,  and  whether 
the  bread  and  other  food  products  are  properly  wrapped  and  pro- 
tected against  handling,  dirt,  dust  and  flies  during  transportation 
and  while  on  sale. 

At  soda-fountains  and  other  places  where  beverages  are  sold,  the 
special  points  to  be  noted  are  cleanliness  of  methods,  including 
proper  washing  of  glasses  and  other  utensils,  and  proper  protec- 
tion from  fly  and  dii't  contamination.  Such  glasses  are  used  many 
times  a  day  and  should  be  accordingly  most  strictly  looked  after. 
Particular  attention  should  be  given  to  the  rims  of  the  glasses 
which  have  been  experimentally  shown  to  harbor  numerous  germs ; 
after-washing  in  clean  water  is  therefore  important. 

At  markets,  especially  those  in  which  produce  usually  eaten 
without  peeling,  paring  or  cooking  is  sold,  special  atttention 
should  be  paid  to  fruits  and  vegetables,  whether  they  are  protected 
against  flies  and  contamination  while  on  display  or  in  transporta- 
tion or  storage,  and  whether  they  are  kept  on  stands  high  enough 
above  the  ground  to  prevent  the  access  of  domestic  animals. 

Food  poisoning.  The  Sanitary  Code  requires  (chapter  II,  regu- 
lation 41)  that  if  a  public  health  nurse  learns  of  the  occurrence 
of  a  number  of  cases  of  severe  or  fatal  illness  believed  to  have 
been  due  to  the  consumption  of  articles  of  food  suspected  to 
have  been  spoiled  or  poisonous,  it  shall  be  her  duty  to  report 
the  same  immediately,  by  telephone  or  telegi-aph  when  practicable, 
to  the  State  Commissioner  of  Health  and  to  the  local  health 
officer  in  whose  jurisdiction  the  cases  occur. 

The  Abatement  of  Nuisances 

Nuisances.  A  nurse  is  not  expected  to  undertake  the  abatement 
of  nuisances  beyond  the  limit  of  what  can  be  accomplished  by 
advice  and  a])[)eal.  But  it  is  well  within  her  province  to  make  a 
thorough  inspection  of  the  premises,  and  if  she  finds  any  condi- 


Public  Health  N"ursing  33 

tion  of  nuisance  which  she  is  not  able  to  have  corrected  by  friendly- 
advice  or  persuasion  to  report  the  case  to  the  local  health  officer, 
who,  as  agent  for  the  board  of  health  upon  whose  action  and  direc- 
tion the  case  depends,  will  proceed  with  its  abatement  in  accord- 
ance with  the  Public  Health  Law  and  the  procedure  given  in 
chapter  VI  of  the  Sanitary  Code. 

It  is  essential  that  the  public  health  nurse  bo  familiar  with  the 
subject  of  nuisances  and  the  manner  in  which  they  are  abated, 
although  the  responsibility  for  their  abatement  rests  upon  the 
health  officer  and  the  board  of  health. 

Abatement.  While  the  subject  may  be  viewed  from  many 
angles,  for  practical  reasons  it  will  be  helpful  to  look  at  it  from 
only  three,  viz:  classihcation  of  nuisances;  statutory  require- 
ments to  be  met ;  procedure  to  be  followed. 

In  regard  to  classification,  nuisances  may  be  considered  under 
various  groupings,  as,  for  instance,  those  prescribed  by  the  Penal 
C/ode;  or  as  major  and  minor  nuisances;  or  with  reference  to  nat- 
ure of  the  materials  responsible  for  the  nuisance,  such  a:s  organic 
and  inorganic;  or  with  reference  to  the  objects  affected,  such  as 
a  pollution  of  the  air,  soil  or  water.  To  the  health  offi(;ial, 
however,  the  most  important  and  practical  classification  would 
include,  first,  those  nuisances  which  directly  affect  healtii; 
second,  those  which  only  indirectly  affect  health;  and,  third, 
those  which  may  l)e  considered  as  more  appropriately  fall- 
ing under  other  municipal  jurisdiction.  These  classes  are 
obviously  arranged  in  the  order  of  their  relative  importance  from 
the  standpoint  of  health,  though  not  necessarily  in  the  proper 
order  from  other  standpoints. 

The  first  of  these  three  important  classes  referred  to  —  viz., 
nuisances  which  directly  affect  health  —  will  include  such  con- 
ditions as  cause  infection  of  water  supplies ;  infection  of  milk  and 
other  food  supplies;  the  breeding  of  mosquitoes,  flies  and  other 
infection  carriers ;  in  fact  any  condition  which  may  be  the  source 
or  vehicle  of  transmission  of  disease  germs.  jSTuisances  arising 
from  such  conditions  are  clearly  of  primary  importance,  and 
should  be  abated  without  question  or  hesitation,  and  strictly  in 
accordance  with  the  procedure  laid  down  by  the  Public  Health 
Law  and  the  Sanitary  Code. 
2 


34  State  Department  of  Health 

The  second  class  of  nuisances,  those  which  indirectly  affect 
health,  will  include  a  variety  of  objectionable  conditions  which  only 
in  an  indirect  way  may  be  associated  with  disease  transmission, 
but  which  do  offend  the  senses,  disturb  the  digestion  or  nervous 
system,  and  in  these  and  other  ways  indirectly  affect  health.  Under 
this  class  may  be  cited  odorous  and  unsightly  piles  of  decaying 
vegetables,  fruits  and  other  organic  but  noninfectious  materials; 
odors  froni  privies  the  contents  of  which  may  not  be  exposed  or 
even  accessible;  obnoxious  gases  and  fumes  from  chemical  and 
other  industrial  plants;  garbage  and  manure  piles;  dirty  pig  pens 
and  fowl  yards,  etc.  In  all  these  cases  and  with  the  limitations 
stated,  there  is  no  direct  opportunity  for  disease  transmission. 
The  effect  upon  the  senses  may  be  offensive  and  even  sickening, 
but  not  productive  of  specific  disease.  In  other  words,  these 
nuisances  only  indirectly  affect  health.  JsTumerically,  it  is  the 
largest  class  a  health  official  has  to  deal  with,  but  unfortunately 
it  is  the  one  of  which  the  ordinary  layman  usually,  but  errone- 
ously, exaggerates  the  importance  from  the  health  standpoint. 

This  kind  of  nuisance  is  frequently  the  most  difficult  for  a 
health  officer  to  dispose  of,  and  it  is  one  where  he  should  err,  if  at 
all,  on  the  side  of  safety  in  regard  to  the  necessity  for  abatement. 
rie  should  not  dismiss  such  a  case  from  his  mind  or  fail  to  act 
merely  because  it  is  not  a  direct  menace  to  health.  It  is  an  actual 
nuisance  from  the  standpoint  of  offensive  odors,  unsightliness,  or 
of  even  ordinary  decency,  and  he  should  have  it  promptly  abated. 
Tactful  discrimination,  moral  suasion  and  appeal  to  civic  pride 
and  justice  will  usually  be  sufficient  to  accomplish  this.  It 
is  important  to  remember  idso  that  in  dealing  with  any  case 
which  may  be  scientifically  questionable  as  to  its  effect  upon 
health,  the  health  officer  cAn  always  fall  back  oii  the  argument  or 
principle  of  its  indirect  effect,  be  it  nausea,  discomfort,  lack  of 
sleo})  or  I'est,  or  the  irritation  and  depression  of  the  nervous  sys- 
tem. In  brief,  the  health  officer  should  make  up  his  mind,  without 
prejudice,  whether  the  case  is  one  which  upon  its  full  merits 
should  be  abated,  and  then  should  procetnl  with  its  abatement.  If 
the  case  should  go  to  court  the  judge  will  usually  be  on  the  health 
officer's  side,  for  judges  fortunately  are  gen(M-ally  both  hunuin  and 
fair  minded. 


Public  Health  JSTursing  3i5 

The  third  class  of  nuisances  referred  to, —  those  which  more 
appropriately  fall  under  other  municipal  jurisdiction, —  will 
include  those  cases  which,  though  they  may  in  some  respects 
indirectly  affect  health,  yet  are  of  such  a  nature  as  to  come  wholly 
or  in  part  under  police  or  other  authority.  This  class  includes 
howling  dogs  and  cats,  blasting,  motorboat  and  automobile  ex- 
hausts, unsightly  fire  rains,  powder  magazines,  dangerous  exca- 
vations, etc.  Even  smoke  nuisances  are  by  some  authorities  con- 
sidered outside  the  province  of  health  authorities,  in  large  cities 
quite  properly  so-.  Many  of  these  have  special  smoke  ordinances 
and  special  smoke  inspection.  In  dealing  with  nuisances  of  this 
class  the  health  officer  usually  finds  it  more  effectual  to  turn  them 
entirely  over  to  the  police  or  other  proper  authorities,  or  at  least 
to  act  in  cooperation  with  these  officials. 

As  to  the  question  of  statutory  requirements,  the  principal 
thing  to  remember  is  that  there  are  certain  classes  of  nuisances 
which,  owing  to  their  scientific  aspect,  or  their  being  outside  the 
territory  of  local  jurisdiction,  concern  more  the  State  Department 
of  Health  than  the  local  board  of  health;  in  particular  those 
provisions  of  the  law  which  cover  sewage  and  industrial  waste 
discharge  and  the  abatement  of  violations  of  rules  and  regula- 
tions enacted  by  the  State  Commission  of  Health  for  the  protec- 
tion of  public  water  supplies  from  contamination.  In  all  cases  of 
sewage  and  waste  discharge  into  streams,  except  perhaps  indi- 
vidual house  drains,  the  State  Commissioner  of  Health  has  direct 
jurisdiction  under  Sections  76-84  of  the  Public  Health  Law.  All 
such  cases  should  be  referred  by  the  health  officer  to  the  State 
Department  of  Health  for  disposition.  In  the  case  of  a  private 
drain,  where  a  local  nuisance  is  created,  the  health  officer  obtains 
more  prompt  and  effective  results  by  considering  it  as  falling 
under  Class  I  or  II  and  applying  the  corresponding  procedure 
in  its  abatement. 

In  cases  of  violation  of  water  rules  affecting  public  water  sup- 
plies the  special  provisions  of  Sections  70-73  of  the  Public  Health 
Law  apply.  These  cases  involve  a  very  specific  and  complex  pro- 
cedure for  abatement.  The  health  board  is  involved  at  only  one 
stage  of  this  procedure,  and  since  the  board  must  act  in  accord- 
ance with  specific  orders  from  the  State  Commissioner  of  Health, 


36  State  Department  of  Health 

the  health  officer  should  refrain  from  any  action  whatever  until 
Buch  explicit  orders,  which  are  always  self-explanator}%  are  actu- 
ally issued. 

With  these  two  exceptions  then,  the  abatement  of  all  nuisances 
which  involve  action  by  the  local  health  officer  will  fall  under 
Sections  21,  2G,  31  and  32  of  the  Public  Health  Lajw  and  Chaptei 
VI  of  the  Sanitary  Code;  this  brings  up  at  once  the  final  question, 
procedure.  It  is  essential  that  the  health  nurse  should  read 
Chapter  VI  very  carefully,  for  these  sections  provide  not 
only  the  authority  but  the  definite  procedure  which  the  health 
officer  must  follow  in  the  abatement  of  all  nuisances  within  his 
jurisdiction.  It  should  be  remembered  that  Sections  21,  26,  31 
and  32  give  full  authority  to  investigate  and  abate  nuisances 
and  Chapter  VI  of  the  Sanitaiy  Code  outlines  the  definite  pro- 
cedure to  be  followed. 

In  the  ordinary  routine  of  abatement  of  nuisances  it  will,  of 
course,  only  occasionally  be  necessary  to  resort  to  any  formal  pro- 
ceedings, since  mere  suggestions  and  advice,  fortified  perhaps  by 
tact  and  diplomacy,  will  usually  accomplish  results  without  coer- 
cive means.  If,  however,  the  case  is  important,  or  appears  in  any 
way  stubborn,  the  health  officer  should  be  notified  and  he  will 
usually  take  the  formal  procedure  outlined  in  Chapter  VI  of  the 
Sanitary  Code  and  follow  it  step  liy  step.  This  course  will  not 
only  at  once  make  a  strong  impression  upon  the  offender,  but  it 
will  protect  the  health  officer  from  any  embarrassment  that  may 
possibly  arise  from   any  subsequent  court  proceedings. 

Should  a  case  be  referred  directly  or  on  appeal  to  the  State 
Department  of  Health,  it  will  still  fall  under  Chapter  VI  of  the 
Sanitary  Code  and  will  usually  be  first  referred  ])ack  to  the  healtli 
officer  for  action.  If  the  health  officer  fails  to  act,  or  if  the  Com- 
missioner reverses  the  decision  of  the  local  health  board,  the 
Commissioner  will  probably  issue  an  order  under  Section  26  of 
the  Public  Heidth  Law  which  is  enforceable  In-  mandamus  pro- 
ceedings. It  will  be  seen,  therefore,  that  Chapter  VI  of  the  Sani- 
tary Code,  furnishes  a  jjrocedure  which  is  to  Ix^  followed  not  alone 
by  the  health  officer,  but  also  by  the  State  Conunissioner  of  Health  ; 
Sections  1,  2  and  3  furnishing  the  procedure  to  be  talcen  by  the 
health  officer  and  health  board  in  those  cases  which  are  disposed 


Public  Health  Nuksing  S'Y 

of  by  the  local  health  board  without  intervention  of  the  State 
Department  of  Health;  and  sections  4,  5  and  6,  the  procedure  by 
the  local  board  and  the  State  Commissioner  of  Health  in  cases 
which  are  referred  to  the  Department  directly,  or  on  appeal. 

In  dealing  with  nuisances,  then,  it  is  essential  to  know  these  pro- 
visions of  the  law  thoroughly,  and  to  follow  them  explicitly. 
There  is  one  feature,  however,  in  the  application  of  these  laws 
about  which  one  should  be  cautious  and  that  is  in  the  application 
of  forceful  means  in  the  abntement  of  a  nuisance.  Sections  31  and 
32  of  the  Public  Health  Law  empower  the  health  officer  to  enter 
property  and  by  forceful  means  to  abate  any  nuisance.  These 
means,  however,  are  rarely  resorted  to  except  in  extreme  cases,  if 
at  all.  The  simpler  and  more  effective  method  will  nearly  always 
be  to  take  the  case  into  court  and  impose  a  fine  or  secure  an 
injunction  or  both.  This  method  will  avoid  serious  personal 
enmity,  insure  a  fair  trial  and  leave  a  more  salubrious  moral 
impression  upon  other  possible  offenders  or  upon  the  community 
at  large,  than  where  martial  law,  as  it  were,  is  declared  and  force- 
ful entry  and  possiljle  destruction  of  property  is  resorted  to. 


38  State  Department  of  Health 


CHAPTER  III 
Pure  Milk  Supplies 

The  Sanitary  Code  of  the  State  of  Xew  York  prohibits  the  sale 
of  milk  at  retail  without  a  written  permit  from  the  health  officer 
of  the  municipality  in  which  the  milk  is  sold.  This  permit  must 
be  renewed  annually.  The  health  officer  or  his  representative  is 
required  to  make  a  yearly  inspection  of  every  dairy  farm  where 
milk  is  produced  for  sale  at  retail  within  his  district,  after  receiv- 
ing an  application  for  a  permit,  and  to  score  such  dairy  farms  on 
scorecards  prescribed  by  the  State  Commissioner  of  Health.  The 
health  officer  may  accept  at  his  discretion  the  inspection  and  scor- 
ing by  the  health  officer  or  his  representative  of  another  munici- 
pality, including  'New  York  City.  The  regulations  governing 
the  production  and  sale  of  milk  and  milk  products  may  be  found 
in  Chapter  III  of  the  Sanitary  Code,  and  in  various  sections  of 
the  Agricultural  Law  (sections  30  to  104). 

It  is  improbable  that  a  nurse  would  be  assigned  to  regular 
inspection  and  scoring  of  dairies,  but  in  the  presence  of  an  epi- 
demic of  communicable  disease  she  may  be  called  upon  to  assist 
the  local  health  officer  in  the  inspection  of  all  places  offering  milk 
for  sale  at  retail.  The  public  health  nurse  may  be  required  also 
to  make  an  investigation  of  conditions  existing  on  some  particular 
dairy  farm  or  farms  if  an  outbreak  seems  to  be  milk-borne,  or  to 
inspect  dairies  maintaining  insanitary  conditions.  When  making 
such  investigations  her  duties  will  consist  in  verifying  the  state- 
ments of  the  producer  that  the  regulations  to  be  observed,  if  the 
milk  is  offered  for  sale,  are  being  strictly  carried  out,  and  in 
certifying  to  the  local  health  officer  the  conditions  found,  the 
methods  of  disposal  of  the  discharges  of  sick  persons,  the  oppor- 
tunities for  flies  to  convey  the  infective  agent  of  the  disease  to  the 
milk  supply,  etc.  She  is  also  expected  to  give  special  instructions 
to  the  family  as  to  methods  of  conducting  the  isolation  period  of  a 
communicable  disease  in  the  home.  The  nurse  may  be  assigned 
to  go  from  house  to  house  in  certain  districts  during  an 
^epidemic,  giving  instructions  to  those  who  desire  or  need  it, 
as  to  the  proper  method  of  caring  for  milk  in  the  home.     In  the 


Public  Health  Nursing  39 

summer  or  during  the  presence  of  an  unusual  amount  of  diarrheal 
disease  among  children  this  is  very  imj^ortant.  When  needed  she 
should  help  the  family  construct  a  cheap  ice  box  such  as  is 
described  at  the  end  of  this  chapter,  and  assure  herself  that  con- 
tainers are  sterilized  before  being  returned  to  the  retail  dealers. 
'No  milk  bottles  should  be  peiinitted  to  leave  a  house  while  an 
inmate  is  ill  of  any  communicable  disease  without  sterilization 
by  methods  approved  by  the  health  officer. 

When  searching  for  the  source  of  typhoid  fever  apparently  milk- 
borne,  the  nurse  is  required  to  visit  farms  or  dealers  to  see  if  any 
]xa-sous  are  ill  with,  or  convalescent  from,  typhoid  fever,  or  give  a 
history  of  a  previous  attack  of  this  disease,  or  of  an  illness  sug- 
gesting but  not  recognized  as  an  attack  of  typhoid  fever.  The 
nurse  is  also  expected  to  inform  herself  concerning  the  existence 
of  a  milk  station  in  the  neighborhood  which  may  be  shipping 
milk  to  another  municipality,  in  order  to  determine  whether 
there  is  any  possibility  of  that  milk  supply  being  contaminated. 

In  order,  therefore,  to  carry  out  these  investigations  and  instruc- 
tions for  the  control  and  prevention  of  disease  caused  by  milk,  the 
public  health  nurse  should  be  informed  as  to  the  principal  facts 
upon  which  is  based  the  production  of  a  pure  milk  supply. 

Impure  milk  is  perhaps  responsible  for  more  sickness  and  death 
than  all  other  foo.ds  combined.  The  reasons  for  this  are:  (1) 
bacteria  grow  well  in  milk;  (2)  of  all  foodstuffs  milk  is  the  most 
difficult  to  obtain,  handle,  transport  and  deliver  in  a  clean,  fresh 
and  wholesome  condition;  (3)  it  is  the  most  readily  decomposable 
of  foods;  and  (4)  it  is  the  only  standard  article  of  diet  obtained 
from  animals  which  is  habituall}'  consumed  in  its  raw  state. 
About  16  per  cent  of  the  average  dietary  in  the  United  States  con- 
sists of  milk  and  milk  products.  Fresh  milk  products  made  from 
infected  milk  may  be  nearly,  if  not  quite,  as  dangerous  as  the  milk 
itself.  Milk,  properly  modified,  is  a  perfect  food  for  the  suckling 
and  is  so  largely  used  as  food  by  adults  as  well  as  infants  that 
there  is  every  reason  to  encourage  the  production  of  pure  milk 
and  to  discourage  and  prevent  the  marketing  of  impure  milk. 

Quality  of  milk.  The  qualities  by  which  milk  is  judged  are  its 
freshness,  purity,  cleanliness  and  wholesomeness.  Milk  is  said  to 
be  fresh  when  its  condition  and  composition  are  the  same  as  when 


40  State  Depaetment  of  Health 

it  was  drawn  from  the  cow.  Milk  is  pure  when  it  is  fresh  and 
clean,  that  is,  when  its  condition  and  composition  are  unchanged 
and  it  is  not  contaminated  with  foreig7i  substances.  When  milk 
is  fresh,  pure  and  clean  it  is  wholesome. 

Bacteria  in  milk.  Milk  as  it  comes  from  a  healthy  cow  is 
usually  wholesome,  but  it  readily  undergoes  changes,  due  princi- 
pally to  the  action  of  bacteria  which  enter  the  milk  after  it  is 
drawn  from  the  cow.  that  render  it  unwholesome.  The  bacteria 
ordinarily  found  in  milk  are:  (1)  those  producing  lactic  acid; 
(2)  those  causing  femientation  and  putrefaction;  (3)  the  germs 
of  human  disease;  and  (4)  beneficial  and  inert  bacteria. 

Lactic  acid  bacteria  decompose  sugar,  changing  it  to  lactic 
acid  which  is  a  harmless  product.  The  bacteria  of  putrefaction 
change  proteins  to  sul>stances  which  may  be  detrimental  t(i 
health,  especially  in  infants.  The  genns  of  human  diseases  if 
introduced  into  milk  may  live  and  multiply,  producing  the  dis- 
ease of  which  they  are  the  infectious  agents  in  those  Avho  drink  the 
milk.  Not  all  bacteria  are  harmful.  Some  produce  beneficial 
changes  in  milk,  such  as  those  which  give  the  agreeable  flavors  to 
butter  and  cheese ;  others  bring  about  no  apparent  changes  in  milk 
or  its  products. 

Impaired  quality  in  milk  is  chiefly  due  to  the  following  changes: 
(1)  souring  or  lactic  acid  fennentation ;  (2)  coagulation  or  curd- 
ling; (3)  unpleasant  taster  and  odors;  and  (4)  the  presence  of 
bacteria  in  excess. 

Souring  is  the  most  common  change  which  takes  place  in  milk 
and  is  due  to  lactic  acid  bacteria.  Sometimes  when  milk  or  cream 
is  ke[)t  too  long,  even  at  a  temperature  which  prevents  souring, 
putrefactive  changes  may  occur  which  will  render  it  unfit  for 
food. 

Coagulation  is  produced  when  a  considerable  quantity  of  lactic 
acid  is  present  in  milk  the  lactic  acid  uniting  with  the  phosphates 
wliich  hold  t]i(>  protein  in  solution,  so  that  a  semi-solid  curd  or 
casein  is  furnicd.  Milk  nuiy  b<>  curdled  also  by  artificial  fer- 
ments such  as  rennet.  Curdled  milk  obtained  from  clea^n  milk, 
if  kej)t  under  clean  conditions,  is  a  wholesome  food. 


Public  Health  Nursing  41 

8limy  or  ropy  mill'.  Certain  bacteria  growing  in  milk  may 
produce  mucilaginous  substances.  The  entire  milk  product  of  a 
dairy  has  been  known  to  become  viscid  in  this  way.  Though 
such  milk  is  considered  a  delicacy  in  some  countries,  in  this 
country  it  is  not  so  regarded.  It  is  not  injurious,  however,  from 
a  standpoint  of  health,  unless  it  is  slimy  as  a  result  of  diseased 
conditions  in  the  mammary  glands. 

Thin  and  watery  milk  is  produced  at  times  by  bacteria  yielding 
ferments  that  dissolve  and  decompose  proteins.  The  products  of 
this  decomposition  are  often  harmful. 

Tastes  and  odors.  Unpleasant  tastes  and  odors  in  milk  are 
usually  caused  by:  (1)  dirt  in  the  milk;  (2)  certain  foods  of  cows, 
like  turnips  or  wild  garlic;  (3)  the  action  of  bacteria  causing 
fermentation  and  decay.  Tastes  and  odor  due  to  food  may  be 
reduced  or  removed  by  the  process  of  aeration  when  the  milk  is 
run  in  a  thin  film  over  the  cooler.  Unpleasant  tastes  are  often 
evidence  of  the  presence  of  harmful  bacteria. 

The  harmful  effects  caused  by  milk  used  as  food  are  produced 
either  by  unwholesome  chemical  compounds  developed  in  the  milk, 
or  by  human  disease  germs  introduced  into  it.  Chemical  products 
affect  health  within  a  few  hours  after  the  milk  is  taken  into  the 
body.  Sickness  caused  by  disease  germs  in  milk  does  not  develop 
until  the  expiration  of  the  period  of  incubation  of  the  disease, — 
that  is  to  say,  from  a  few  days  to  a  week  or  more,  during  which 
time  many  persons  may  become  infected.  Disease  germs  rarely  if 
ever  produce  changes  in  milk  which  are  recognizable,  and  the  first 
manifestation  of  their  presence  is  usually  the  development  of  the 
disease  in  a  number  of  persons  who  have  been  using  the  same  milk. 
Under  these  circumstances  the  milk  should  be  held  under  suspicion 
and  an  investigation  made  to  determine  the  cause.  Investigation 
of  the  qiudity  of  a  milk  supply  is  always  required  when  tracing 
the  origin  of  an  epidemic. 

Bacterial  count.  Almost  all  of  the  harmful  effects  due  to  milk 
are  the  result  of  bacterial  action.  One  of  the  most  reliable  indica- 
tions of  the  quality  of  milk  is  the  number  of  bacteria  present  in 
each  cubic  centimeter.  This  number  is  estimated  by  a  bacterial 
count  which  is  the  basis  upon  which  milk  is  usually  graded  by 
boards  of  health.       All  milk  contains  some  bacteria  —  the  best 


42  State  Department  of  Health 

milk  on  the  market  a  few  thousands,  ordinary  milk  hundreds  of 
thousands,  and  poor  milk  millions  of  bacteria  in  each  cubic  centi- 
meter. 

A  sample  of  milk  for  a  bacterial  analysis  is  taken  in  a  sterilized 
container  which  holds  about  half  an  ounce.  The  milk  is  first 
stiiTed  or  shaken  thoroughly  in  order  to  distribute  the  bacteria 
uniformlj'.  The  bottle  is  then  nearly  filled  and  aseptically 
sealed,  th(^  container  is  surrounded  with  ice  to  prevent  the  bacteria 
from  growing  and  is  forwarded  pi'omptly  to  a  labo.ratoiy  as  soon 
as  possible. 

A  bacterial  count  does  not  indicate  the  total  number  of 
bacteria  present  in  a  sample  of  milk,  but  only  the  number  of  bac- 
teria that  will  develop  colonies  in  the  culture  medium  employed, 
and  at  the  temperature  and  within  the  given  period  of  incubation. 
The  standard  methods  of  counting  are  those  which  have  been 
adopted  by  the  American  Public  Health  Association,  experience 
having  shown  that  these  methods  give  the  most  uniform  results 
and  afford  a  fairly  reliable  indication  of  the  quality  of  the  milk. 

Adulteration  of  milk.  The  common  adulterations  of  milk  are: 
(1)  skimming;  (2)  watering;  (3)  thickening  agents,  coloring 
matter,  alkalies,  sweet  substances;  and  (4)  chemical  preservatives. 

Skimming  or  removal  of  part  or  all  of  the  cream  and  selling  the 
balance  as  whole  milk  is  fraud  but  has  no  reference  to  health, 
except  that  the  milk  is  lowered  thereby  in  nutritive  value.  Adding 
skimmed  milk  is  also  a  form  of  adulteration  often  difficult  to 
detect.  Watering  milk,  if  the  water  be  pure,  is  also  to  be  regarded 
more  as  a  fraud  than  a  health  problem.  The  addition  of  water  to 
milk  lowers  its  specific  gravity,  raises  its  freezing  point  and 
also  lowers  its  viscosity.  Thickening  agents  such  as  challv, 
calves'  brains  or  glycerine  are  not  commonly  used.  Coloring 
matter,  such  as  annate  (a  vegetable  dye)  is  sometimes  added  to 
milk  with  the  object  of  concealing  skimming  or  watering,  or  to 
make  tlio  milk  look  richer.  Alkalis,  such  as  sodium  carbonate  or 
l)icarboiiate,  are  occasionally  added  to  milk  to  reduce  its  acidity  or 
to  dchiy  curdling.  Sweet  sul)stances,  such  as  saccharine  and 
sugar,  are  sometimes  added  to  milk  either  to  raise  its  specific 
gravity    and  thns   disguise    watering    or    to    disguise    the    sour 


Public  Health  Nursing  43 

taste  of  milk  just  on  the  turn.  Chemical  preservatives,  such  as 
borax  and  boric  acid,  salicylic  acid,  benzoic  acid  and  benzoin, 
peroxide  of  hydrogen,  formaldehyde,  etc.,  have  been  used  in  milk. 
No  satisfactory  chemical  preservative  for  milk  has  been  dis- 
covered which  will  kill  the  bacteria  or  prevent  their  growth  with- 
out injuring  the  milk.  Almost  all  states  and  countries  prohibit 
the  use  of  such  foreign  substances. 

Dirty  mill:  —  the  dirt  test.  Practically  all  milk  contains 
some  dirt.  Milk  that  contains  visible  dirt  nearly  always  has  a  high 
bacterial  count.  A  rough  test  for  visible  dirt  is  to  observe  the  sedi- 
ment deposited  on  the  bottom  of  a  milk  bottle  or  other  container. 
The  presence  of  dirt  may  be  more  accurately  determined  by  the 
sediment  test,  which  consists  in  filtering  a  pint  of  milk  through  a 
little  disc  of  absorbent  cotton.  This  leaves  a  stain  varying  in 
intensity  from  a  yellowish  to  a  brownish  or  black  spot.  A  good 
crucible,  a  Lorenz  apparatus,  or  simply  an  ordinary  funnel  may 
be  used  to  filter  the  milk.  Ordinaiy  milk  will  usually  leave  a  con- 
siderable number  of  visible  specks  of  dirt  in  the  cup.  Warm  milk 
filters  more  rapidly  than  cold  milk.  The  sediment  test  is  one  of 
the  most  practical  of  the  routine  tests  used  for  the  public  health 
control  of  milk  supplies.  It  may  he  made  use  of  in  educating 
farmers  and  dairymen  as  well  as  consumers  regarding  the  relation 
of  cleanliness  to  the  wholesomeness  of  milk.  The  discs  may  be 
dried  and  kept  with  the  records  of  the  dairy  in  the  health  of&ce. 
Milk  that  has  been  "  clarified  "  or  strained  of  course  will  not 
show  a  sediment. 

Composition.  The  composition  of  milk  is  exceedingly  complex. 
It  consists  chiefly  of  wate]%  several  proteins  in  suspension,  fats  in 
emulsion,  sugar  and  a  number  of  inorganic  salts  in  solution ;  also 
ferments  as  well  as  antibodies,  cells,  gases,  etc.  The  market  value 
of  milk  depends  upon  the  quantity  as  well  as  the  quality  of  its 
various  food  elements,  particularly  protein,  fat  and  sugar.  The 
percentage  of  these  three  elements  are  of  special  importance  in 
calculating  the  diet  of  infants.  Experience  has  shown  that  reliable 
results  are  obtained  when  the  percentage  of  cow's  milk  is  taken  to 
be  3.5  per  cent  protein,  4  per  cent  fat  and  5  per  cent  sugar.  Since 
milk  varies  in  composition,  minimum  standards  have  been  set  by 
law.     The  standard  of  New  York  State  is  that  milk  shall  con- 


44  State  Department  of  Health 

tain  at  least  3  per  cent  of  fat  and  11.5  per  cent  of  total  solids. 
The  sale  of  milk  below  this  standard  of  composition  is  illegal 
(Agricultural  Law,  section  30). 

Test  for  fat.  There  is  accurate  test  for  the  amount  of  fat  which 
is  known  as  the  "  Babcock  Test."  It  depends  upon  the  fact  that 
sulphuric  acid  added  to  milk  acts  upon  the  protein  and  liberates; 
the  fat,  wliich  then  floats  on  the  mixture  when  its  amount  may  be 
measured. 

Specific  gravity  test  for  adulteration.  Milk  containing  the 
legal  amount  of  fat  and  solids  will  have  a  specific  gravity  of 
1.030  to  1.034.  The  specific  gravity  test  is  usually  made  with  a 
special  bulb  called  the  "  lactometer,"  but  an  ordinai-y  urino-meter 
may  be  used.  Fat  being  lighter  than  the  rest  of  the  milk  if  it 
is  removed  the  specific  gravity  of  the  skimmed  milk  will  be  more 
than  1.034.  The  addition  of  water  to  milk  lowers  the  specific 
gravity  below  1.030.  A  specific  gravity  of  more  than  1.034  thus 
indicates  that  the  milk  has  been  skimmed,  while  a  specific  gravity 
below  1.030  indicates  that  it  has  been  watered.  Taking  the 
specific  gravity  of  the  whole  milk  does  not  of  itself  detect  either 
skimming  or  watering,  since  if  these  practices  are  done  artfully, 
the  specific  gravity  of  the  milk  may  remain  unchanged.  If  these 
are  suspected,  therefore,  from  the  appearance  of  the  milk,  further 
laboratory  tests  are  required. 

Total  solids.  The  laboratory  test  for  the  determination  of  total 
solids  is  by  evaporation  and  direct  weighing  of  the  dried  residue. 

Wholesome  mill\  The  four  main  conditions  which  must  be 
observed  in  the  production  of  wholesome  milk  are:  (1)  that  it  be 
taken  from  healthy  cows;  (2)  that  it  be  handled  by  healthy  dairy- 
men; (3)  that  it  be  produced  by  clean  methods;  and  (4)  that  it 
be  pre3erved  as  nearly  as  possible  in  its  original  state  of  purity. 

Diseases  spread  hy  milk.  The  diseases  most  commonly  spread 
by  milk  are:  tuberculosis,  typhoid  fever,  diphtheria,  scarlet  fever. 
se])tie  sore  throat,  malta  fever  and  foot  and  mouth  disease,  also 
some  of  the  summer  com])laints  of  children  and  the  diarrheal  and 
dysenteric  disesiscs  •  ndulls.  Tlieso  are  often  traceable  to 
infected  milk. 

Diseases  of  animal  ori-gin.  As  a  I'ule  milk  becomes  infected 
from  human  sources,  sometimes  on  the  farm,  sometimes  at  the 


Public  Health  Nursing  45 

dairy,  sometimes  in  transportation  and  occasionally  in  the  house- 
hold. Not  infrequently  the  milk  becomes  infected  as  a  result  of 
disease  of  the  cow,  as  in  the  case  of  bovine  tuberculosis. 

Bovine  tuberculosis.  This  is  the  most  common  disease  which 
may  be  transmitted  from  cows  to  human  beings.  Children,  it  is 
now  known,  are  particularly  susceptible  to  the  bovine  type  of 
tubercle  bacillus  while  adults  are  not.  The  principal  organs  which 
are  affected  with  this  form  of  tuberculosis  are  the  lymph  glands  of 
the  neck  and  the  abdominal  organs,  the  lungs,  the  bones  and  joints. 

Tuberculosis  is  so  common  among  cows  that  sometimes  nearly  all 
animals  in  a  herd  are  infected.  The  disease  may  be  recognized 
in  cows  by  three  methods:  (1)  physical  examination;  (2)  finding 
tubercle  bacilli  in  the  excretions;  and  (3)  by  the  tuberculin  test. 
Every  cow  found  to  be  tuberculous  is  to  be  considered  as  a  possible 
menace  to  pu])lic  health.  The  laws  of  New  York  State  require 
that  all  cows  known  to  be  tuberculous  shall  either  be  killed  or  kept 
under  conditions  prescribed  by  the  State  Commissioner  of  Agri- 
culture.     (Agricultural  Law,  section  94.) 

It  is  a  very  difficult  matter  to  discover  tubercle  bacilli  in  milk. 
The  measures  resorted  to  in  oixler  to  secure  a  milk  supply  free 
from  living  tubercle  bacilli  are  as  follows:  (1)  the  detection  of 
tuberculous  cows  and  their  exclusion  from  the  herd;  (2)  cleanly 
methods  of  milk  production;  and  (3)  the  pasteurization  of  all 
milk.  The  latter  is  the  only  method  upon  which  complete  reliance 
can  be  pla€ed. 

Diseases  of  human  origin  spread  hy  milk.  Milk  is  a  culture 
medium  favorable  to  the  growth  of  disease  germs.  Cases  of  milk- 
borne  disease  frequently  occur  singly  or  in  epidemic  form,  depend- 
ing upon  the  number  of  persons  using  the  infected  milk.  The 
germs  are  usually  conveyed  to  the  milk  by  those  who  handle  it, 
and  the  source  of  the  infection  is  either  the  discharges  from  the 
nose  and  throat  of  such  persons  in  coughing  or  sneezing,  or  the 
dairyman's  hands  soiled  with  these  discharges  or  with  the  excre- 
tions from  the  intestines  of  the  cattle.  Milk-bome  epidemics  of 
diphtheria,  scarlet  fever  and  septic  sore  throat  are  common. 

The  communicable  diseases  mentioned  in  the  Sanitary  Code  of 
New  York  State  as  being  likely  to  be  transmitted  by  milk  am: 


46  •  State  Depaktment  of  Health 

diphtheria,  septic  sore  throat,  amebic  or  bacillary  dysentery,  epi- 
demic cerebrospinal  meningitis,  scarlet  fever,  smallpox,  typhoid 
fever,  paratyphoid  fever,  acnte  anterior  poliomyelitis  and  cholera. 

When  a  case  of  one  of  those  diseases  occurs  on  a  farm  or  dairy 
producing  milk  or  milk  products,  the  code  specifies  that  no  milk 
or  daily  products  shall  be  sold  or  delivered  unless  the  conditions 
required  are  observed,  or  a  permit  be  issued  by  the  local  health 
officer  allowing  the  food  to  be  sold  or  delivered.  As  a  preventive 
measure  an  efficient  inspection  service  strikes  at  the  root  of  the 
milk  problem.  But  inspection  h:is  its  limitations;  it  can  not 
detect  disease  carriers  or  mild  cases  of  diseases,  and  inspectors 
can  not  be  on  hnnd  at  all  places  ;it  all  times.  An  essential  factor 
of  a  successful  inspection  is  the  scorecard  system. 

The  scorecard  system.  The  common  standard  by  which  the 
wholesomeness  of  milk  is  judged  is  the  bacterial  count.  A  low 
bacterial  count  is  dependent  upon  the  exclusion  of  dirt  from  the 
milk  and  cleanliness  in  eveiy  stage  of  its  production.  The  sources 
of  dirt  and  bacteria  in  any  given  milk  supply  can  only  be  dis- 
covered by  a  careful  inspection  of  the  dairy  and  close  observation 
of  the  methods  which  are  followed  in  handling  the  milk.  The 
points  to  be  noted  in  making  such  inspection  are  indicated  on 
the  official  scorecards  which  have  been  adopted  by  various  depart- 
ments of  health.  The  scorecard  should  be  used  in  inspecting 
dairies,  but  dairy  scores  are  an  imperfect  means  of  judging  the 
quality  of  the  milk  produced  as  determined  by  bacteriological 
tests.  The  omission  of  a  single  sanitary  measure  such  as  clean- 
ing the  udder  of  a  cow  may  cause  the  milk  to  have  a  high  bacterial 
couni  even  though  the  total  score  of  the  dairy  may  be  good.  The 
principle  upon  which  scoring  is  based  is  that  of  cleanliness  of 
ever)'thing  surrounding  the  milk,  including  dairymen,  cows, 
stables,  milk  room  and  utensils. 

Pasteurization.  The  measures  taken  for  the  production  of  milk 
with  low  bacterial  count  are:  (1)  preventing  bacteria  from  enter- 
ing the  milk;  (2)  preventing  bacteria  from  growing  and  multiply- 
ing in  milk;  and  (8)  killing  the  bacteria  in  the  milk.  The  meas- 
ures adopted  for  preventing  bacteria  from  entering  the  milk  have 
already  been  referred  to.     The  only  practical  method  of  killing 


Public  Health  ISTursing  47 

bacteria  in  milk  is  the  application  of  heat;  the  prevention  of  their 
growth  and  multiplication  is  effected  by  the  application  of  cold. 

Milk  may  be  preserved  by  boiling  as  in  the  canning  of  fruits 
and  vegetables.  This  is  the  process  used  in  making  condensed 
or  evaporated  milk ;  but  boiling  and  evaporation  changes  the 
composition  and  taste  of  milk.  It  is  preferable  to  sterilize  the 
milk  without  changing  it  to  any  extent.  The  process  of  pasteuriza- 
tion does  this  by  the  application  of  a  low  degree  of  heat  for  a  con- 
siderable length  of  time.  The  standard  of  pasteurization  adopted 
by  the  'New  York  Slate  Department  of  Health  is  the  exposure  of 
milk  to  a  temperature  of  142°-145°  F.  for  not  less  than  30 
minutes.  This  degree  of  temperature  and  period  of  time  are  suffi- 
cient to  kill  pathogenic  bacteria  as  well  as  those  which  are  peculiar 
to  the  intestinal  tracts  of  cows  without  changing  the  composition 
and  taste  of  milk.  Immediate  rapid  chilling  of  the  milk  to  50°  F. 
or  lower  is  essential.  One  test  of  efficiency  in  pasteurizing  is 
a  comparison  of  the  bacterial  count  before  and  after  pasteuriz- 
ing. Another  test  is  the  absence  of  colon  bacilli  in  the  pasteur- 
ized milk,  for  colon  bacilli  derived  from  manure  are  usually 
present  in  all  raw  commercial  milk. 

When  a  milk-borne  epidemic  breaks  out  it  may  become  necessary 
to  pasteurize  an  entire  milk  supply  to  make  it  safe  for  use. 

An  emergency  method  of  pasteurization  is  to  place  the  cans  in 
a  tank  of  boiling  water,  stirring  the  milk  continually  to  distribute 
the  heat,  testing  with  a  thermometer,  and  removing  the  cans 
when  the  temperature  reaches  14^5°  F.  If  the  cans  are  placed  in 
a  warm  loom  the  temperature  of  the  milk  will  be  retained  at  about 
140 '^  F.  for  half  an  hour.      Prompt  cooling  should  follow. 

The  home  pasteurization  of  milk  is  sometimes  desirable  when 
infant  food  is  to  be  prepared,  or  a  milk-borne  epidemic  is  threat- 
ened. For  this  purpose  the  milk  may  be  heated  in  a  double- 
boiler,  stirred  until  its  temperature  by  the  thermometer  reaches 
145°  F.  and  then  placed  on  the  back  of  the  stove,  where  it  remains 
at  140°  F.  for  30  minutes,  after  which  it  should  be  projnpth 
cooled.  To  correct  any  possible  tendency  to  rickets  in  children 
fed  exclusively  on  pasteurized  milk,  orange  juice  is  given. 

Cooling  milk     The  only  practical  method  of  restraining  the 


48  State  Department  of  Health 

growth  and  multiplication  of  hacteria  in  milk  is  by  cooling  the 
wiilk  as  soon  as  possible  after  it  is  drawn  from  the  cow  and  keeping 
it  cool  during  storage  and  transportation.  Milk  is  commonly 
cooled  by  allowing  it  to  run  in  a  thiji  film  over  a  cooler  con- 
taining cold  water  or  ice.  A  flat  cooler  enclosed  in  a  case  is 
preferable  to  the  cone-shaped  container  often  used,  as  the  latter  is 
liable  to.  become  contaminated  with  dust  or  flies.  A  method  of 
cooling  milk  frequently  adopted  on  farms  and  at  small  dairies  is 
to  place  the  cans  in  cold  spring  water.  The  purity  of  the  water  in 
such  cases  is  of  great  importance,  as  some  of  it  may  enter  the  can. 

Gradhig  milk.  Milk  is  graded  by  its  quality  and  not  by  its 
composition.  The  grades  are  determined  by  scoring  the  dairy  or 
by  a  bacterial  count,  or  sometimes  by  a  combination  of  both 
methods.  The  grades  of  milk  which  are  recognized  by  the  New 
York  Stat-e  Department  of  Health  and  the  basis  of  the  grading  are 
given  in  the  Sanitary  Code  of  the  State  (chapter  III,  reg.  13). 

Permits.  Permits  issued  by  a  health  officer  are  required  for  the 
sale  of  milk  in  this  State.  These  pei'mits  are  issued  after  an  appli- 
cation has  been  filed  with  the  health  officer  by  the  dealer  and 
every  dairy  from  which  his  milk  is  obtained  is  inspected  by  the 
health  officer  or  his  representative.  While  the  system  of  permits 
does  not  insure  a  pure  milk  supply,  it  affords  a  means  by  which 
unsatisfactory  dealers  may  be  controlled  and  both  consumers  and 
producers  may  be  educated  in  matters  regarding  wholesome  milk. 

Procedures  with  suspected  milk.  Should  a  sample  of  milk  be 
suspected  to  be  unwholesome  and  be  brought  to  the  attention  of  a 
public  health  nurse,  she  may  adopt  the  following  procedures:  (1) 
inspect  the  conditions  under  which  the  milk  has  been  kept  after 
delivery,  since  changes  may  have  been  brought  about  in  the  milk 
by  conditions  for  which  the  buyer  or  consumer  is  responsible,  such 
as  time  and  temperature  of  storing,  the  manner  of  storage,  etc. ; 
(2)  place  the  sample  in  plenty  of  ice  and  send  or  take  it  at  once  to 
a  laboratory  for  examination,  stating  the  condition  under  which 
the  sample  was  obtained;  (3)  trace  the  milk  to  the  dealer  and 
dairyman,  and  ascertain  the  conditions  under  which  it  was  pro- 
duced and  delivered ;  (4)  keep  a  detailed  record  of  all  information 
obtained  and  report  it  to  the  health  officer. 


Public  Health  Nursing 


49 


The  iceless  ice  box.  A  refrigerator  without  the  use  of  ice  can 
be  conveniently  constructed  by  enveloping  a  screened  set  of  shelves 
in  a  canton-flannel  jacket  which  can  be  buttoned  around  it  and 
kept  moistened  by  wicks  of  the  same  material  placed  in  a  pan  of 
water  on  top  of  the  box,  moisture  from  the  pan  being  allowed  to 
drip  on  the  sides  of  the  box  and  keep  the  enveloping  flannel 
moistened  —  as  shown  in  the  drawing.     The  evaporation  of  this 


A    Box  of  screened  shelveB. 
B   Pan  of  water  on  top  of  box. 
C    Pan  beneath  box  for  drippinga. 
D   Canton-flannel  jacket  kept  moistened  by 
wicks  of  same  material. 


Iceless  Refrioeratok 

moisture  will,  in  a  relatively  dry  climate,  maintain  a  temperature 
of  about  50°  F.*  in  the  ice  box  and  make  the  use  of  ice  unneces- 
sary or  help  to  preserve  ice  that  may  be  used.  Keep  in  a  shady 
place,  where  the  air  circulates  freely. 

*  While  this  temperature  is  not  low  enough  for  prolonged  storage,  it  is 
suflficient  to  keep  food  and  milk  for  a  short  time,  as  is  often  done  in  a  cool 
cellar. 


50  State  Depaktment  of  Health 


CHAPTER  IV 
Pure  Water  Supplies 

The  securing  of  pure  water  supplies  for  human  use  constitutes  a 
specialty  in  engineering,  but  a  public  health  nurse  may  be  called 
upon  to  assist  in  the  work.  If  in  his  judg-ment  it  is  desirable  a 
health  officer  may  utilize  the  services  of  a  nurse  employed  by  the 
board  of  health  in  the  investigation  of  specific  instances  of  sus- 
pected pollution  of  water  supplies.  Such  instances  will  probably 
be  confined  to  the  investigation  of  conditions  surrounding  farm- 
houses, shacks  and  temporary  colonies  of  people  where  typhoid 
fever;  dysentery  or  other  water-borne  diseases  may  be  communi- 
cated through  careless  disposal  of  human  excrement,  or  where  a 
carrier  may  be  suspected  or  known  to  be  found.  The  nurse  may 
thus  be  exp(>cted  to  report  on  the  location  and  number  of  cases  of 
the  disease  or  of  knoAvn  or  suspected  carriers,  the  method  of  the 
disposal  of  their  excrement  and  present  an  accurate  description 
of  the  conditions  which  suggest  possible  contamination  of  the 
water  supply.  This  repoii;  might  well  include  a  sketch  or  map 
sliowing  the  location  of  wells  and  springs,  streams  and  other 
sources  of  the  water  supply,  and  their  distance  from  and  relation 
to  the  place  where  the  contaminating  agent  is  deposited. 

It  is  essential,  therefore,  that  the  public  health  nurse  should 
know  what  a  pure  water  supply  is  and  how  to  recognize  it,  and  for 
this  reason  she  should  be  familiar  with  the  rudimentary  principles 
which  control  the  production  of  pure  water  on  the  one  hand,  and 
with  the  simpler  methods  of  sewage  disposal  on  the  other. 

Pure  water.  The  importance  of  having  pure  water  in  the  home 
is  axiomatic.  Public  water  supplies  are  usually  beyond  the  scope 
and  ability  of  the  nurse  to  control,  but  in  small  or  rural  com- 
munities where  public  water  supplies  do  not  exist,  or  where,  if  they 
do  exist  in  part,  recourse  is  often  had  to  wells  and  springs  for 
drinking  purposes  because  the  water  is  colder,  it  becomes  of 
great  value  to  the  public  health  nurse  to  have  some  definite  knowl- 
edge of  the  principles  governing  the  securing  of  pure  water,  as  the 
pollution  of  these  sources  is  common  and  can  often  be  remedied  by 
comparatively  simple  means. 


Public  Heai.th  Kubsing  51 

The  quantity  of  water  which  is  used  in  a  household  varies 
according  to  circumstances.  Five  gallons  of  water  per  person 
daily  is  considered  to  be  a  very  small  amount  in  a  household  that 
has  no  plumbing.  If  a  house  is  provided  with  running  water,  a 
bath  room  and  flush  toilet,  at  least  twenty-five  gallons  per  person 
will  be  used  daily  for  all  purposes.  In  cities  the  quantity  of  water 
supplied  is  from  seventy-live  to  three  hundred  gallons  daily  per 
capita. 

The  term  "  pure  water  "  as  applied  to  water  supplies  is  difficult 
to  define  in  a  strictly  scientific  manner.  To  all  intents  and  pur- 
poses a  pure  water  is  one  the  use  of  which  for  drinking  purposes 
will  promote  health  rather  than  cause  disease.  A  water  to  be  pure 
and  suitable  for  potable  purposes  should  be  clear,  colorless,  odor- 
less, palatable,  and  free  from  metallic  poisons  and  from  disease 
germs. 

The  only  water  which  approaches  chemical  purity  is  that  which 
has  been  freshly  distilled.  All  so-called  pure  waters  contain  a  con- 
siderable amount  of  substances  dissolved  in  them,  such  as  gases 
and  minerals  of  various  kinds.  The  substances  that  are  found  dis- 
solved or  held  in  suspension  in  water  may  be  harmless  foreign 
substances  or  dangerous  impurities.  A  foreign  substance  which  is 
harmful  or  objectionable  is  called  an  impurity. 

Hard  water.  Hard  water  is  that  in  which  a  considerable 
amount  of  lime  or  magnesia  is  dissolved.  These  minerals  do  not 
make  the  water  unwholesome,  but  they  are  objectionable  in  house- 
hold water,  as  soap  docs  not  lather  well  in  such  water,  forming 
insoluble  compounds  with  the  salts  of  lime  and  magnesium,  which 
float  as  a  scum  on  the  surface  or  become  entangled  with  the  meshes 
of  the  cloth  in  washing.  Hard  water  is  thus  not  desirable  for  bath 
or  laundry  purposes.  Water  which  contains  50  parts  or  more 
per  million  of  hardness  is  usually  classed  as  hard.  Hardness  in 
water  is  of  two  kinds,  temporary  and  permanent.  The  lime  or 
calcium  carbonate  is  much  more  soluble  in  the  presence  of  cai-bon 
dioxide  and  when  a  water  containing  lime  held  in  solution  by 
carbon  dioxide  is  boiled  the  lime  is  precipitated  out,  due  to  the 
driving  ofi^  of  the  carbon  dioxide.  The  hardness  thus  driven  out 
of  solution  by  boiling  is  called  temporary,  while  the  remainder  is 
called  permanent. 


52  State  Department  of  Health 

Iron.  Iron  in  a  water  supply  is  frequently  derived  from 
minerals  in  the  soil,  but  it  is  sometimes  due  to  corrosion  of  water 
pipes.  Iron  is  not  unwholesome  in  water,  but  if  present  in  any 
considerable  quantity  (one  part  or  more  of  iron  in  one  million  of 
water),  it  renders  the  water  undesirable  for  bath  or  laundry  work. 
One  remedy  for  iron  in  water  is  to  allow  the  water  to  stand  in  the 
tank  or  reservoir  for  some  hours,  and  then  drain  off  the  clear 
water  on  top  without  the  sediment. 

When  Avater  contains  a  large  proportion  of  iron,  a  micro- 
organism called  crenothrix  may  grow  in  it  and  form  a  jelly-like 
coating  inside  of  the  pipes  and  tanks.  Pieces  of  this  growth  may 
break  off  and  float  in  the  water,  or  may  die  and  impart  to  it  an 
unpleasant  taste  or  odor,  or  may  form  a  scumlike  oil  on  the  surface 
of  the  water.     It  is,  however,  harmless  to  health. 

Irnpiirifies.  Impurities  in  water  may  be  divided  into  those 
which  make  it  unsafe  for  internal  use,  as  in  drinking  and  cooking, 
and  those  which  render  it  unfit  for  exteraal  use,  as  for  bathing  and 
laundrying,  cleaning,  etc.  A  public  health  nurse  is  mostly  inter- 
ested in  the  unsafe  impurities  which  are  found  in  drinking  water, 
as  these  have  direct  effect  on  health.  It  is  unsafe,  how- 
ever, to  use  an  impure  water  for  any  purpose  in  a  household,  as 
there  is  always  a  risk  of  some  of  the  water  getting  into  the  mouth. 
Water  that  is  discolored,  or  cloudy,  or  deposits  a  sediment,  or  has 
an  unpleasant  taste  or  odor,  should  be  regarded  with  suspicion  and 
as  unsafe  to  use,  unless  it  has  been  proved  to  be  safe.  At  the  same 
time,  not  all  water  that  is  apparently  clean,  bright  and  sparkling, 
is  safe  as  such  water  may  contain  invisible  germs  of  disease. 

Again,  impurities  may  be  classified  according  to  their  character 
into  physical,  chemical  and  bacteriological  impurities.  Physical 
impurities  are  those  which  are  suspended  in  water,  such  as  iron 
rust,  particles  of  clay  and  mud,  shreds  of  wood,  leaves,  etc.,  the 
presence  of  which  is  indicated  by  the  turbidity  of  the  water.  They 
are  themselves  seldom  harmful  to  health,  but  their  presence  is  an 
indication  that  harmful  substances  may  also  be  present.  Chemical 
impurities  are  those  which  are  dissolved  in  water,  such  as  mineral 
impurities,  partially  decomposed  organic  matter  and  ptomaines, 
etc.,  produced  during  the  process  of  decay.  Mineral  matter  in 
water  seldom  affects  health  except  in  the  case  of  metallic  poisons. 


Public  Health  Kuesing  53 

such  as  lead.  Organic  matter  in  water  and  the  products  of  its 
decomposition  are  rarely  harmful  in  themselves  unless  the  water  is 
grossly  polluted  with  them.  Of  all  impurities  found  in  water 
by  far  the  most  important  in  relation  to  their  effect  on  health 
are  bacteria.  Water  can  cause  disease  only  when  living  bacteria  of 
disease  or  some  metallic  poison  are  present  in  it.  These  bacteria 
are  so  minute  as  to  be  invisible  and  the  clearness  of  the  water 
is  therefore  no  indication  that  they  may  not  be  present.  The 
chief  diseases  which  may  be  transmitted  to  human  beings  by 
means  of  water  containing  bacteria  are  typhoid  fever,  para- 
typhoid fever,  dysentery  and  cholera.  Tubercle  bacilli  and 
rarely  found  in  a  water  supply,  but  their  existence  is  possible 
if  the  water  is  grossly  polluted  from  a  case  of  tuberculosis. 
The  principal  impurities  in  water  to  be  guarded  against  from  a 
public  health  standpoint  are  the  excretions  of  human  beings, 
especially  of  persons  who  give  off  disease  germs.  The  harmful 
impurities  include  sewage,  household  drainage,  the  contents  of 
cesspools  and  privies,  and  other  collections  of  matter  containing 
human  excretions. 

Detection  of  impui'ities.  Impurities  in  water  are  detected:  (1) 
by  a  sanitary  inspection  of  the  source  of  the  water  and  its  environ- 
ment; (2)  by  a  chemical  analysis;  and  (3)  by  a  bacteriological 
analysis.  All  of  these  methods  must  be  applied  in  order  to  form 
an  accurate  judgment  of  any  given  water  supply.  The  omission  of 
any  one  of  them  may  lead  to  a  false  conclusion. 

A  public  health  nurse,  in  making  a  sanitary  survey  of  the  source 
of  a  water  should  inspect:  (1)  the  source  itself;  (2)  the  method  of 
collecting  and  distributing  the  water;  and  (3)  the  presence  of 
sewage  and  other  human  pollution,  such  as  cesspools  and  household 
drainage. 

Water  supply.  Water  supplies  may  be  classified  according  to 
their  sources  into  (1)  rain  water;  (2)  surface  water,  as  that  from 
streams  and  lakes;  and  (3)  underground  water  from  wells  and 
springs.  Each  source  of  supply  has  its  own  particular  problems 
for  solution. 

Rain  water.  Rain  water  is  usually  collected  from  roofs  and 
stored  in  underground  cisterns.  Theoretically,  water  as  it  falls 
through  the  air  contains  the  least  amount  of  foreign  matter  of  all 
natural  waters.     Cisterns  often  contain  coiLsiderable  amounts  of 


54  State  Department  of  Health 

foreign  matter,  however,  the  sources  of  which  are  for  the  most 
part :  (1)  dust  and  bacteria  from  the  air;  (2)  dust,  dirt  and  excre- 
ment of  birds  from  the  roofs  of  houses;  (3)  dust  and  dirt  enter- 
ing through  the  covers  of  cisterns;  (4)  substances  dissolved  from 
the  masonry  of  the  cistern.  The  remedy  for  dust  and  dirt  coming 
from  the  air  and  collecting  roofs  is  to  discard  the  first  water  which 
falls  during  a  shower  and  to  collect  only  that  which  falls  after 
the  roofs  have  been  washed  off.  A  simple  device  may  be  attached 
to  the  main  conductors  by  which  the  water  may  be  turne<l  otf 
and  on  to  the  cistern.  The  most  important  impurities  in  cistern 
water  from  a  sanitary  standpoint  are  those  which  get  into  it  from 
improper  protection ;  gross  pollution  may  enter  the  cistern  in  this 
way.  The  nurse  should  especially  note  the  following  conditions 
about  a  cistern:  (1)  tightness  of  the  cover  and  its  ability  to  exclude 
earth  worms,  bugs,  sand  and  waste  water;  (2)  provision  for  con- 
ducting waste  water  away  from  the  vicinity  of  the  cover;  (3)  per- 
meability of  the  sides  to  sewage  and  ground  water;  (4)  practice  of 
washing  hands  and  soiled  articles  of  clothing,  etc.  at  the  cistern ; 
and  (5)  frequency  and  care  with  which  the  cistern  is  cleaned. 

Eain  water,  being  soft,  is  suitable  for  use  in  the  laundry.  On 
the  whole,  however,  it  is  not  considered  as  practicable  for  general 
domestic  use  as  good  surface  or  ground  water. 

Surface  water.  The  water  of  springs,  rivers  and  lakes  in  unin- 
habited regions  is  naturally  pure  and  wholesome,  except  during 
times  of  flood  when  it  becomes  turbid.  Even  then  it  will  not 
contain  the  germs  of  human  diseases,  unless  polluted  with  the 
excretions  of  human  beings.  A  safe  water  supply  for  a  household 
must  be  derived  from  an  uninhabited  region,  or  the  water  must  be 
purified  before  it  is  distributed. 

The  possible  sources  of  pollution  of  streams,  rivers  or  laies  are 
determined  by  a  sanitary  survey  of  the  watershed  in  order  to  dis- 
cover: (1)  tlie  presence  of  sewage  and  drainage  from  premises  that 
are  occupied  or  used  by  human  beings;  and  (2)  the  probability  of 
any  objectionable  material  entering  the  water.  The  principles  are 
the  same  whether  applied  to  a  small  stream  on  a  hillside  or  a  large 
river.    The  points  to  bo  investigated  are : 

(1)  The  topography:  The  height  and  direction  of  the  slopes  of 
the  land;  the  existence  of  valleys  and  tributary  streams  leading  to 
the  water ;  the  character  of  the  soil. 


Public  Health  ISTursing  55 

(2)  The  presence  of  sources  of  pollution:  Houses,  tents,  shacks 
and  workshops  used  by  human  beings ;  barns,  stables  and  enclosures 
for  domestic  animals ;  cultivated  fields  and  manure  piles ;  drainage 
from  highways;  sewage  disposal  plants  and  dumping  places  for 
rubbish, 

(3)  Systems  of  sewage  disposal :  Sewers  and  privies  emptying 
directly  into  the  water ;  cesspools,  privies,  and  household  drainage, 
their  efficiency  and  the  care  given  them;  existence  of  gross  soil 
pollution. 

In  making  such  a  survey  the  following  conditions  must  be  taken 
into  consideration :  The  diy  season,  the  period  of  floods,  and  the 
time  of  frozen  ground.  Sewage  deposited  on  frozen  ground  dur- 
ing the  winter  may  be  released  suddenly  in  the  spring  by  a  thaw 
and  carried  to  a  water  supply,  which  at  any  other  season  of  the 
year  could  not  be  reached. 

Underground  water.  Ground  water  that  is  clear  and  pleasant 
to  the  senses  will  practically  never  contain  foreign  substances  harm- 
ful to  health,  unless  it  is  polluted  with  human  impurities.  A 
sanitary  inspection  of  the  well  and  its  surroundings  will  nearly 
always  show  the  probable  source  of  any  such  impurities,  if  there  be 
any  present. 

In  the  case  of  springs  and  wells  in  limestone,  it  is  difficult  to 
determine  from  the  sanitary  survev'  alone  whether  opportunities 
for  pollution  exist  or  not,  on  account  of  the  existence  of  far-reach- 
ing channels  and  crevices  in  the  rock  formation. 

Impurities  may  enter  the  well  itself,  or  the  containers,  or  pump 
with  which  the  water  is  drawn  or  they  may  reach  the  water  by 
seepage  through  the  soil. 

Wells.  Wells  are  of  two  kinds,  dug  and  driven  wells.  The 
usual  form  of  dug  well  consists  of  a  pit  3  or  4  feet  in  diameter, 
lined  with  brick  or  stone  and  open  at  the  top.  It  is  exposed  to 
pollution  from  substances  falling  into  its  open  mouth  or  penetrat- 
ing the  joints  of  its  lining.  A  driven  well  consists  of  a  pipe  of 
iron  or  tiling  sunk  down  to  the  underground  layer  of  water.  It  is 
thus  protected  from  substances  falling  or  entering  into  it  through 
its  sides.  If  properly  constructed  this  form  of  well  furnishes  water 
as  pure  as  the  underground  stratum  of  water  from  whence  it  is 
drawn. 


56  State  Department  of  Health 

The  requirements  for  a  safe  well  arc  (1)  that  it  be  in  itself  a 
safe  source;  and  (2)  that  it  be  protected  by  proper  construction 
from  possible  contamination.  In  order  to  be  safe  in  itself,  the  well 
should  be  located  so  that  the  drainage  from  a  privy  or  cesspool  or 
any  other  underground  repository  of  human  excreta  and  washings 
can  not  drain  toward  the  well ;  or,  in  case  it  does,  that  the 
distance  of  the  well  from  such  source  of  pollution  and  the  char- 
acter of  the  soil  be  such  that  the  drainage  shall  be  completely 
purified  during  its  passage  through  the  soil. 

The  first  point  for  the  public  health  nurse  to  take  into  con- 
sideration in  inspecting  a  well  should  be  the  possibility  of  sub- 
surface pollution.  In  the  absence  of  definite  knowledge  as  to  the 
subsoil  or  ground  water  from  which  the  supply  is  drawn,  a  wide 
margin  of  safety  should  be  allowed.  The  physical  and  hydraulic 
conditions  surrounding  the  well  which  will  either  preclude  the 
drainage  reaching  the  well  or  will  cause  its  purification  are  often 
somewhat  complex  in  nature  and  difiicult  to  determine  by  inspec- 
tion only;  a  chemical  and  a  bacteriological  analysis  of  the  water 
are  frequently  required  to  confirm  an  opinion.  As  a  rule,  however, 
the  solution  of  the  matter  is  simple.  One  can  nearly  always  deter- 
mine the  general  direction  of  ground  water  flow  from  the  slope 
of  the  ground  since  it  almost  always  flows  in  the  direction  of  the 
surface  slope,—  at  least  so  far  as  the  flow  near  the  surface  is  con- 
cerned. So  that  in  most  cases  of  wells  and  springs  we  may  safely 
conclude  that  if  there  are  no  sources  of  pollution  such  as  privies, 
cesspools,  barnyards,  etc.,  on  the  territory  above  the  well  in  the 
direction  of  the  slope  of  the  ground  toward  it,  there  will  be  com- 
paratively little  chance  of  pollution  of  the  underground  water 
reaching  the  well.  Any  sources  of  pollution  on  the  lower  side  of, 
or  at  one  side  of  and  not  close  to  the  well,  will,  except  in  rare 
instances,  not  pollute  the  well. 

It  should  be  borne  in  mind,  however,  that  while  sources  of 
water  that  are  located  uphill  from  possible  sources  of  pollution 
are  in  general  safer  than  those  which  are  lower  down,  this  is  not 
invariably  the  case,  for  the  ground  water  level  may  at  times  slope 
in  the  opposite  direction.  Again,  crevices  and  underground 
streams  may  exist  in  rocky,  hard  or  clayey  soils  and  convey  pollu- 
tion from  relatively  distant  points.  In  such  cases  it  is  usually 
necessary  to  supplment  observations  with  a  laboratory  analysis, 


Public  Health  Nursing  57 

in  order  to  determine  the  extent  of  any  pollution  or  purifi- 
cation. Depth  is  also  to  be  considered.  Deep  driven  wells  are 
less  subject  to  pollution  than  shallow  wells.  In  general  it  may- 
be said  that  possible  sources  of  pollution  within  100  feet  or  so 
should  be  regarded  with  more  or  less  suspicion.  Privies  within 
this  distance  should  be  of  the  sanitary  type,  that  is,  they  should 
have  water-tight  pits  or  receptacles  which  are  regularly  cleaned 
out  and  the  contents  removed  to  a  safe  place. 

Surface  contamination  should  then  be  looked  for.  Many  wells 
are  perfectly  safe  as  far  as  the  underground  sources  are  concerned 
and  yet  are  very  unsafe  owing  to  the  contamination  through  sur- 
face drainage  in  time  of  rain  which  may  enter  the  top  of  the  well 
through  loose  walls  or  by  leaky  covers.  Indeed,  the  most  frequent 
source  of  contamination  of  wells  improperly  constructed  at  the  sur- 
face probably  comes  from  the  diiiy  condition  of  the  ground  around 
the  well,  from  shoes  of  persons  standing  upon  leaky  covers  and 
from  washing  of  the  hands  in  drawing  water,  etc.,  all  of  which 
tend  to  pollute  the  water  in  the  well. 

Protective  construction  of  wells.  There  are  many  means  of 
protection  of  wells  against  their  surface  sources  of  contamination ; 
but  the  simplest  and  best  in  dug  wells,  is  to  have  the  well  properly 
lined  with  brick  or  stone,  which  within  a  few  feet  of  the  top  should" 
be  constructed  of  watertight  masonry  such  as  concrete,  the  well 
curb  being  carried  a  foot  or  more  above  the  surface  of  the  ground. 
The  space  around  the  walls  should  then  be  graded  in  such  a  man- 
ner that  the  ground  surface  will  slope  away  in  all  directions  from 
the  well.  If  located  on  a  hillside  drainage  ditches  should  be  made 
above  the  well  to  deflect  the  surface  drainage.  The  cover  should 
be  made  water-tight  by  constructing  it  of  concrete,  or  if  wood  is 
employed,  a  double  covering  of  matched  and  leaded  tongue  and 
groove  boards  should  be  used.  An  additional  precaution  is  to  carry 
all  waste  water  from  the  pump  in  a  trough  to  a  point  outside  and, 
if  possible,  on  the  lower  side  of  the  well  so  that  the  water  will  not 
drain  back  towards  the  well.  The  pipe  for  the  pump  should  be 
connected  by  means  of  water-tight  joints.  Open  wells,  like  the 
old-fashioned  bucket-wells,  should  never  be  used,  as  they  are  most 
liable  to  contamination. 

While  many  cases  may  arise  which  call  for  a  more  extended 


68  State  Department  of  Health 

knowledge  than  the  principles  above  outlined,  which  apply  equally 
to  springs  as  to  wells,  if  the  public  health  nurse  will  familiarize 
herself  with  these  and  will  use  common  sense  and  judgment,  she 
will  be  able  in  most  cases  to  form  a  correct  opinion  as  to  the  prob- 
able safety  of  private  supplies,  and  be  in  a  position  not  only 
to  report  her  findings  to  the  health  officer,  but  to  explain  to  the 
householders,  should  occasion  arise,  how  to  remedy  simple  con- 
ditions which  are  apparently  unsafe. 

Sanitary  analysis  of  water.  A  complete  sanitary  analysis  of 
water  includes  a  chemical  analysis  to  determine  the  nature  of  the 
water  and  amount  of  chemical  impurities  present  and  a  bacteriolo- 
gical examination  to  estimate  the  number  and  determine  the  kind 
of  bacteria.  The  chemical  and  bacteriological  examination  of 
water  is  the  work  of  an  expert  and  the  interpretation  of  the  results 
obtained  requires  experience  and  judgment.  Standard  methods 
for  water  analysis  have  been  established,  after  careful  considera- 
tion by  a  committee  of  the  American  Public  Health  Association, 
and  these  have  been  adopted  by  common  consent  for  certain  rou- 
tine work  as  giving  the  most  uniform  results.  Crude  tests  which 
may  be  made  at  home  or  in  the  office  by  the  average  physician 
or  nurse  have  little  or  no  value;  but  the  nurse  may  be  required 
to  take  a  specimen  of  water  for  analysis.  She  should,  therefore, 
be  familiar  with  the  methods  of  collecting  samples  of  water  for 
examination. 

Chemical  analysis.  Taking  specimens  of  water  for  analysis 
requires  considerable  knowledge  and  care  in  order  to  avoid  con- 
tamination of  the  water;  but  it  can  be  done  by  a  nurse  who  is 
trained  in  surgical  cleanliness.  About  two  gallons  of  water  are 
required  for  analysis.  The  containers  must  be  of  glass  or  glazed 
earthenware,  and  be  as  clean  as  possible  inside.  The  stopper  must 
be  of  gTound  glass.  It  is  always  best  to  secure  a  container  from 
the  laboratory.  The  New  York  State  Department  of  Health  fur- 
nishes a  two-gallon  glass  bottle  in  a  wooden  shipping  case  for  tak- 
ing samples  of  water  for  chemical  analysis.  If  the  sample  has  been 
collected  in  a  sterile  container  with  bacteriological  precautions  the 
same  sample  may  serve  for  the  bacteriological  examination. 
Usually,  however,  the  bacteriological  sample  is  collected  separately 
in  a  special  two-oimce  bottle  at  the  same  time.  Care  should  be 
taken  to  secure  a  sample  which  is  thoroughly  representative  of  the 


Public  Health  Nursing  '  59 

water  to  be  analyzed.  If  it  is  taken  from  a  river  or  lake,  the  bottle 
must  be  submerged,  not  too  near  the  bank,  and  allowed  to  fill 
without  disturbing  any  sediment  in  the  water.  If  it  is  from  a 
pump  or  faucet,  the  water  should  be  allowed  to  run  for  several 
minutes  before  filling  the  bottle.  A  blank  form  accompanies  each 
container  for  recording  the  source  of  the  water  and  a  sanitary 
survey  of  its  surroundings,  without  which  the  results  of  the 
nalysis  can  not  be  properly  interpreted.  The  filled  container  must 
be  plainly  marked  and  numbered  for  identification,  corresponding 
with  a  mark  on  the  survey  blank.  The  filled  container  should  be 
sent  or  taken  to  the  laboratory  as  soon  as  possible  after  the  sample 
is  taken. 

Laboratory  report.  Many  different  substances  may  be  found 
m  nearly  every  sample  of  water,  but  tests  are  usually  made  for 
those  only  which  have  a  sanitai-y  significance.  The  chemist  takes 
special  note  of  those  substances  which  indicate  sewage  pollution 
of  the  water,  such  as  the  organic  products  of  decomposition  and 
oxidation.  These  substances  may  be  derived  from  harmless  vege- 
table matter  or  from  the  soil,  but  when  they  are  from  such  sources 
they  are  usually  in  small  amounts  and  have  no  sanitary  import- 
ance. The  amount  of  such  substances  which  are  naturally  in  the 
water  must  be  considered,  therefore,  before  deciding  whether  it  is 
polluted  or  not.  Their  quantity  is  of  greater  significance  than 
their  mere  presence. 

Interpretation  of  a  chemical  analysis.  This  is  often  a  diffi- 
cult matter  which  the  nurse  should  not  be  called  upon  to  decide, 
but  she  should  understand  the  elementary  principles  involved. 

Color  is  usually  an  indication  of  the  quantity  of  vegetable  mat- 
ter dissolved  in  the  water  and  is  generally  present  only  in  surface 
waters.  Grround  waters  are  usually  colorless.  If  water  contains 
iron  it  will  be  perfectly  clear  at  first,  but  will  soon  turn  a  rusty 
yellow.  Color  in  water  should  be  distinguished  from  turbidity. 
True  color  is  due  to  dissolved  impurities,  decaying  vegetable  mat- 
ter, etc. ;  turbidity  is  due  to  substances  held  in  suspension. 

Turbidity  practically  means  muddiness;  it  is  an  indication  of 
the  presence  of  insoluble  matter  in  the  water  and  is  often,  though 
incorrectly,  spoken  of  as  color.  Pure  water  is  clear  and  sparkling, 
but  clearness  and  brilliancy  alone  do  not  mean  purity,  while  tur- 


60  '  State  Department  of  Health 

bid  waters  are  not  necessarily  dangerous  to  health.  All  river  and 
lake  waters  are  more  or  less  turbid,  especially  after  a  rain;  but 
ground  waters  should  never  be  turbid,  and  if  so,  should  at  once 
excite  suspicion. 

Odor  and  taste.  Chemically  jmre  water  is  absolutely  devoid 
of  odor  and  taste  but  it  is  also  insipid  for  a  water  to  be  palatable 
must  contain  dissolved  oxygen.  Odors  in  water  are  objectionable 
rather  than  detrimental  to  health.  As  a  rule,  the  most  objection- 
able odors  develop  in  surface  waters  and  are  caused  by  the  growth 
of  algae,  protozoa  and  other  microscopic  organisms.  The  earthy 
odor  of  some  ground  water  is  due  to  substances  dissolved  during 
its  passage  through  the  soil.  Taste  is  imparted  to  most  waters 
by  the  mineral  matter  or  gases  held  in  solution.  Heating 
a  water  often  brings  out  an  odor  or  taste  not  evident  in  a  cold 
sample. 

The  total  solids,  or  residue  left  on  evaporation  of  a  given 
quantity  of  water  to  dryness,  indicate  the  amount  of  foreign  mat- 
ter that  is  either  dissolved  or  held  in  suspension  in  the  water. 
This  residue  includes  both  organic  and  inorganic  substances.  Loss 
on  ignition  indicates  the  organic  matter  which  may  be  burned  off, 
leaving  the  mineral  residue  which  exists. as  such. 

Hardness  is  a  quality  of  water  which  has  more  of  an  economic 
than  sanitary  importance,  indicating  the  capacity  of  water  to  dis- 
solve soap. 

Chlorine  as  sodium  chloride  or  common  salt  is  a  normal  con- 
stituent of  all  waters.  An  excess  shows  usually  the  presence  of 
sewage  or  the  excretions  of  animals.  A  comparison  of  the  chlorine 
content  of  a  water  with  that  of  other  waters  in  the  general  vicinity 
known  to  be  unpolluted  frequently  aifords  useful  information  as 
to  its  sanitary  quality. 

Ammonia,  nitrites  arid  nitrates.  These  arc  of  considerable 
significance  in  a  water  analysis.  Vegetable  matter  contains  some 
[)rotoin  and  its  decomposition  may  cause  a  small  amount  of 
nitrogenous  substances  to  appear  in  a  water.  A  large  amount 
of  ))r()t(Mn  of  animal  origin  is  contained  in  sewage  and 
drainage  from  dwellings  and  barnyards.  The  organic  matter 
in  water  consists  largely  of  protein    which  is  usually    in    the 


Public  Health  ISTursing  G1 

early  stages  of  decomposition.  Ammonia  is  produced  later  in  the 
process  of  decomposition,  while  nitrites  are  produced  by  the  oxida- 
tion of  the  ammonia,  the  nitrates  being  among  the  final  products 
of  the  process  of  decomposition  of  protein  matter.  Free  ammonia 
as  ordinarily  found  in  drinking  water  is  in  itself  harmless;  its 
significance  lies  in  the  fact  that  it  indicates  the  presence  of  putre- 
fying organic  matter.  Its  presence  in  clear,  properly  stored  rain 
water  has  much  less  significance  than  in  surface  or  ground  water. 
Albuminoid  ammonia  is  a  fairly  correct  index  of  the  amount  of 
organic  pollution  in  water.  Nitrites  in  water  are  regarded  as  a 
special  danger  signal.  The  reason  for  this  is  that  nitrites  indi- 
cate that  active  putrefaction  of  nitrogenous  organic  matter  is  going 
on  as  the  result  of  bacterial  activity.  They  are  never  present 
except  in  small  amounts,  for  they  are  oxidized  to  the  higher  and 
more  stable  nitrates.  The  absence  of  nitrites,  however,  does  not 
mean  that  water  is  necessarily  safe,  for  they  may  be  absent  in 
impure  water,  owing  to  the  fact  that  the  oxidation  of  the  nitrog- 
enous matter  has  not  reached  this  stage  or  perhaps  has  passed  it. 
The  presence  of  nitrites  in  spring  and  deep  well  water  may  be 
without  significance  however,  for  in  some  cases  they  may  be  gen- 
erated by  the  reduction  of  nitrates  which  are  found  in  all  water. 
Nitrates  are  the  end  products  of  the  mineralization  of  organic 
matter  present  in  all  water.  They  indicate  past  or  distant  pol- 
lution. While  the  absence  of  nitrates  does  not  necessarily  mean 
purity,  neither  does  their  presence  necessarily  indicate  immediate 
danger,  unless  found  in  excessive  amounts. 

Bacteriological  examination.  Practically  all  natural  waters 
contain  bacteria,  the  number  and  kind  of  the  bacteria  varying 
greatly  in  different  places  and  under  different  conditions.  The 
bacteria  are  washed  into  the  water  from  the  air,  from  the  soil,  etc. 
The  intestinal  contents  of  animals  pollute  waters  with  enormous 
numbers  of  bacteria,  but  it  is  the  infection  with  certain  species 
from  man  that  makes  water  most  dangerous. 

A  bacteriological  examination  of  water  is  made  in  order  to  detect 
the  probability  of  the  presence  of  living  bacteria  of  disease.  The 
number  of  bacteria  is  not  so  important  as  their  kind,  but  much 
may  be  learned  from  a  simple  enumeration  of  the  bacteria ;  roughly 
speaking,   the  number  of  bacteria   in  water  corresponds  to   the 


62  State  Department  of  Health 

amount  of  organic  pollution.  The  characteristic  bacteria  which 
indicate  pollution  are  the  colon  bacilli  or  those  derived  from  the 
intestines.  Their  presence  in  water  shows  pollution  with  sew- 
age or  the  drainage  from  dwellings  and  barnyards.  Colon  bacilli 
from  man  can  not  b'e  distinguished  from  those  of  the  lower 
animals. 

Collection  of  samites.  A  two-ounce  sample  of  water  is  suf- 
ficient for  a  bacteriological  examination  of  water.  The  container 
must  be  a  clean  glass  bottle  which  has  been  sterilized  and  provided 
with  a  ground  glass  stopper.  The  proper  containers  in  shipping 
cases  are  supplied  by  the  laboratory.  A  sample  is  taken  with  pre- 
cautions to  obtain  an  average  specimen  as  in  taking  samples  for 
chemical  examination  (page  59).  The  stopper  is  removed  immedi- 
ately before  collecting  the  sample.  The  bottle  is  filled  nearly  full 
either  by  immersing  it  in  the  water  or  by  allowing  the  water  to  flow 
into  it.  The  stopper  is  then  replaced  tightly  and  the  bottle  enclosed 
in  the  shipping  case,  ice  packed  around  it,  and  it  is  shipped  or 
taken  to  the  laboratory  at  once.  It  is  important  to  keep  the  sample 
cold  during  transportation  to  prevent  the  multiplication  of  bacteria. 
Every  sample  of  water  for  bacteriological  examination  must  be 
nccompanied  by  data  regarding  the  sanitary  inspection  of  its 
source,  as  in  the  case  of  a  chemical  sample.  Specimens  for  both 
chemical  and  bacteriological  analysis  of  water  are  usually  taken 
from  the  same  source  and  at  the  same  time. 

Bacteriological  report.  A  bacteriological  report  of  an  examina- 
tion of  water  is  usually  very  brief,  containing  two  items  only:  (1) 
the  total  number  of  bacteria  per  cubic  c-entimeter;  and  (2)  the 
presence  or  absence  of  colon  bacilli.  The  number  of  bacteria  re- 
ported is  the  number  of  the  colonies  that  develop  when  1  c.c.  of  a 
specimen  of  water  is  mixed  with  a  suitable  culture  medium  and 
kept  at  a  constant  temperature  for  two  days.  Two  specimens  are 
usually  tested,  one  at  a  temperature  of  68°  F.  and  the  other  at 
98°  F.  The  ordinary  bacteria  of  fermentation  and  decay  grow 
best  at  a  room  temperature  of  68°.  The  bacteria  which  grow  nat- 
urally in  the  human  intestines  develop  best  at  a  temperature  of 
98°  F.  The  report  usually  states  the  number  of  bacteria  which 
develop  at  each  temperature.  When  a  test  is  made  for  the  presence 
of  colon  li:i(',illi  llircc  siu'cimcus  are  usually  taken,  one  containing 


Public  Health  N'ttrsing  63 

10  c.  c.  of  water,  a  second  1  c.  c.  and  a  third  1-10  c.  c.  Each  is 
mixed  with  a  culture  medium  favorable  to  the  growth  of  the  colon 
bacilli  and  which  restrains  the  growth  of  other  bacteria.  The 
report  states  the  presence  or  absence  of  colon  bacilli  in  each 
specimen. 

The  significance  of  colon  bacilli  in  water  is  that  if  they  are 
present  disease  germs  may  also  be  present.  In  interpreting  the 
significance  of  colon  bacilli  in  water  it  is  important  to  know  the 
source  of  the  water  determined  by  a  sanitary  survey  of  the  water- 
shed, as  the  bacilli  may  be  derived  from  a  comparatively  harmless 
source  such  as  the  droppings  of  wild  and  domestic  animals.  The 
absence  of  colon  bacilli  in  water  is  presumptive  evidence  that  the 
water  is  safe  so  far  as  bacteriology  can  prove  it. 

Prevention  of  Impurities  in  a  Water  Supply 

There  are  three  broad  measures  for  the  prevention  of  impurities 
in  a  water  supply:  (1)  the  proper  disposal  of  all  sewage  and 
excrement,  including  the  drainage  from  dwellings  and  barnyards ; 
(2)  the  locating  of  the  water  supply  at  a  point  removed  from  a 
source  of  pollution;  and  (3)  purification  of  the  water.  Cities  are 
often  compelled  to  go  long  distances  in  order  to  obtain  an  unpol- 
luted water  supply.  If  a  river  or  lake  is  used  both  as  a  sewage 
disposal  place  and  as  a  source  of  water  supply  the  question  arises 
as  to  which  is  the  cheaper  and  safer  process,  to  make  other  pro- 
vision for  the  disposal  of  sewage  or  to  purify  the  polluted  water 
to  render  it  fit  for  use.  The  solution  of  this  problem  must  be 
studied  for  each  individual  city. 

Purification  of  water.  The  measures  most  commonly  adopted 
for  the  purification  of  water  are:  (1)  sterilization;  (2)  filtration. 

Sterilization  by  boiling  is  the  most  effective  way  to  make  impure 
water  safe  for  household  use.  The  boiling  temperature  will  kill 
the  bacteria  of  disease  which  may  be  present  in  water.  The  chief 
objection  to  boiling  water  is  that  it  makes  it  taste  flat  and  insipid 
by  driving  off  the  dissolved  oxygen.  The  taste  of  boiled  or  dis- 
tilled water,  however,  may  be  restored  by  aeration,  that  is,  by 
shaking  it  in  a  partly  filled  bottle  in  order  to  bring  it  in  contact 
with  the  air. 

Chlorination  is  the  process  of  sterilizing  water  by  the  addition 


64  State  Department  of  Health 

of  ehloi-iiio  either  in  the  form  of  chh)rine  gas  or  as  chlo]'ide 
of  lime  (bleaching  powder).  From  .25  to  .50  parts  by  weight 
of  chlorine  per  million  of  water  are  usually  sufficient  to  kill 
disease  germs  in  a  fe^v  minutes.  In  the  case  of  grossly  pol- 
luted waters  as  much  as  2.0  parts  or  more  per  million  may  be 
required.  Properly  proportioned,  the  chlorine  imparts  little  or  no 
taste  to  the  water.  The  process  is  adapted  for  sterilizing  the  water 
supply  of  a  city  or  a  small  quantity  of  drinking  water.  The 
United  States  army  uses  tablets  of  chloride  of  lime  to  sterilize  a 
few  quarts  or  gallons  of  water  at  a  time.  The  New  York  State 
Department  of  Health  maintains  a  portable  chlorinating  outfit  for 
emergency  use  in  sterilizing  public  water  supplies  that  suddenly 
have  become  contaminated.  Other  methods  of  sterilization  such 
as  ultra  violet  rays  and  ozone  treatment  are  rarely  used. 

Filtration  is  often  used  for  the  purification  of  water  supplies 
on  a  large  scale.  A  filter  unit  usually  contains  from  three  to  five 
feet  of  fine  sand  underlaid  with  coarse  gravel  and  a  system  of 
underdrains.  The  water  is  applied  at  the  surface  and  drawn  off 
at  the  bottom,  the  impurities  being  removed  by  the  sand.  These 
filtration  plants  are  either  of  the  so-called  slow  or  the  rapid  filtra- 
tion type.  In  the  slow  filtration  type  the  water  is  not  chemically 
treated  before  it  enters  the  bed,  and  the  rate  of  filtration  is  slow, 
usually  from  two  or  three  million  gallons  pier  acre  per  day.  Clean 
sand  alone  has  very  little  filtering  action,  for  the  bacteria  pass 
readily  through  it.  The  efficiency  of  slow  sand  filtration,  there- 
fore, depends  largely  upon  a  natural  jellylike  growth  of  bacteria 
which  takes  place  upon  the  grains  of  sand  in  the  upper  few  inches 
of  the  bed.  This  growth  usually  takes  a  few  weeks  to  form. 
When  the  surface  of  the  sand  has  iDCcome  clogged  with  impurities 
the  bed  must  be  cleaned,  about  one-half  inch  of  sand  with  its 
impurities  being  removed  and  the  filter  bed  then  returned  to  use. 
A  slow  sand  filter  working  properly  will  rk^move  90  per  cent  or 
more  of  the  bacteria  from  water.  In  a  rapid  sand  filter,  the 
water  is  first  treated  with  ahim  or  other  coagulating  chemicals 
which  form  a  coagulent  whicli  lakes  the  place  of  the  jelly-like 
growth  in  the  slow  filter.  This  insures  efficient  filtration  when 
the  rate  of  flow  through  the  sand  IhhI  is  forty  to  fifty  times 
the    rate   of   the   flow    in    a   slow    filter.        A   rapid    sand    filter 


Public  Health  Nursing  65 

usually  must  be  cleaned  every  day  in  order  to  remove  the 
accumulated  impurities  and  flocculent  matter  between  the  grains 
of  sand.  This  cleaning  is  done  by  forcing  water  up  through 
the  filter  from  below  in  a  reverse  direction,  during  which 
time  the  sand  is  agitated  and  the  impurities  washed  out.  While 
either  type  of  filter,  when  it  is  worked  properly,  is  efficient,  it  is 
customary  to  insure  sterilization  of  the  water  by  subsequent 
chlorination. 

Household  filtration.  Most  small  filters  attached  to  kitchen 
faucets  are  of  little  or  no  use.  They  may  even  do  harm  by  intro- 
ducing more  bacteria  than  were  in  the  original  water.  The  only 
household  filters  that  have  a  sanitary  value  are  those  made  of 
unglazed  porcelain  similar  to  the  filters  used  in  bacteriological 
laboratories.  They  are  efficient  in  removing  bacteria,  but  the 
water  passes  through  very  slowly,  and  they  must  be  frequently  and 
thoroughly  cleaned  or  sterilized  or  they  may  become  unsafe  to  use 
from  the  accumulation  of  dirt  and  bacteria. 
3 


66  State  Department  of  Health 

CHAPTER  V 

Disposal  of  Sewage 
From  a  practical  viewpoint  the  subject  of  sewage  disposal  may- 
best  be  treated  by  considering  the  subject  under  two  headings,  the 
disposal  of  sewage  of  the  individual  home,  and  the  disposal  of 
sewage  of  the  institution  or  municipality.  Although  the  strictly 
scientific  princij^les  governing  the  methods  of  disposal  under  both 
these  headings  are  the  same,  practical  considerations  such  as  sim- 
plicity, cost  and  maintenance  make  it  desirable  to  treat  each  class 
separately. 

Disposal  of  Sewage  of  the  Individual  Home 

The  disposal  of  human  excreta  and  sewage  at  the  individual 
home  in  a  manner  that  is  safe  and  at  the  same  time  convenient 
and  simple  has  always  presented  some  difficulties.  This  is  due  to 
the  fact  that  success  depends  not  alone  upon  the  selection  of  proper 
methods  and  upon  good  construction,  but  equally,  if  not  more  so, 
upon  proper  care  and  maintenance. 

In  dealing  with  this  subject  the  first  question  that  should  be 
considered  is  as  to  what  constitutes  a  sanitaiy  method  of  disposal 
of  excreta.  Without  entering  into  any  elaborate  discussion,  this 
question  may  be  answered  by  the  following  requirements: 

1  It  should  not  give  rise  to  a  nuisance,  i.  e.,  should  not  offend 
the  senses  in  any  way, 

2  It  should  not  be  a  menace  to  health,  i,  e.,  should  not  be  a 
means  of  transmission  to  human  beings  of  any  disease  germs  which 
may  be  present  in  the  excreta, 

3  It  should  be  convenient  to  the  house. 

4  It  should  be  free  from  esthetic  objections  in  regard  to  its 
location,  condition  during  use,  or  manner  and  means  of  mainten- 
ance, 

5  Its  operation  should  not  be  affected  by  freezing  weather. 
There  may  be  considered  in  general  two  distinct  methods  of 

disposal  of  sewage,  the  dry  system  and  tlie  water  carriage  system. 


Public  Health  Nursing  67 

The  dry  system  does  not  require  a  water  supply,  and  as  typified 
by  the  ordinary  privy,  either  of  the  dug  type  or  the  removable 
receptacle  type,  is  generally  applicable  for  use  at  the  country  home 
where  the  number  in  the  family  is  small  and  where  economy  is 
a  consideration.  The  other,  the  water  carriage  system,  serving 
the  bath,  toilet,  wash  basin,  sink,  etc.,  requires  an  ample  supply 
of  running  water  in  the  house  delivered  under  pressure  and  is 
applicable  only  where  soil  conditions,  topography,  area  of  land, 
etc.,  are  favorable.  There  is  what  might  be  considered  a  third 
type,  a  sort  of  compromise  between  the  two  systems  which,  how- 
ever, more  nearly  approaches  the  diy  system  and  for  this  reason 
will  be  considered  with  nnd  as  a  modification  of  it. 

The  dry  method  of  disposal  is  essentially  exemplified  by  some 
form  of  privy,  of  which  there  are  in  general  three  types;  the 
underground  vault  or  common  dug  type ;  the  removable  receptacle 
type,  and  a  combination  of  the  former  with  a  subsurface  irriga- 
tion system,  the  liquid  portion  from  the  vault  passing  into  a 
system  of  agricultural  tile  pipe  laid  a  foot  or  more  beneath  the 
surface  of  the  ground. 

For  a  family  of  from  five  to  ten  persons  where  a  simple  and  in- 
expensive method  of  disposal  is  desired,  a  properly  dug  excavation 
properly  shored  with  plank  to  prevent  caving  in,  with  a  privy 
building  over  it  properly  screened,  will  ordinarily  be  found  to 
be  a  sufficiently  sanitary  means  of  disposing  of  human  excreta  to 
meet  most  local  conditions  and  requirements  in  the  country.  It 
presupposes  that  the  water  supply  of  the  home,  if  a  well  or  spring, 
is  located  on  ground  above  the  privy  or  at  least  not  along  the 
same  line  of  drainage  so  that  pollution  can  be  carried  to  it. 

Such  a  type  of  privy  is  shown  in  Fig.  1.  The  excavation 
should  be  about  4  feet  wide  by  5  feet  long,  or  possibly  5  feet  square, 
and  from  5  feet  to  6  feet  deep.  The  sides  should  be  carefully 
shored  with  planks  and  braced  to  prevent  caving  in.  The  earth 
surrounding  the  top  of  the  excavation  should  be  sloped  away  on 
all  sides,  or  a  small  trench  should  be  dug  around  it  to  deflect  any 
surface  water  during  rains.  The  floor  and  sides  of  the  privy  build- 
ing should  be  tightly  boarded,  particularly  around  the  base,  to 
exclude  flies.  The  doors  and  windows  should  be  screened  in  sum- 
mer time  and  the  seat  openings  should  be  provided  with  hinged 
covers.    A  ventilator  may  be  run  from  the  vault  inside  the  build- 


68  State  Department  of  Health 

ing  through  the  roof  with  screen  top,  if  desired.  An  endeavor 
should  be  made  to  keep  the  vault  beneath  the  seats  entirely  closed, 
except  for  the  screened  ventilator,  to  exclude  flies  and  to  prevent 
too  much  circulation  of  air  which  would  intensify  putrefaction 
and  odors.  The  interior  of  the  pri\'y  building  should,  on  the  con- 
traiy,  be  freely  ventilated  through  screened  openings,  since  this 
will  minimize  odors.  The  frequent  sprinkling  of  fine,  dry  earth, 
and  the  occasional  sprinkling  of  chloride  of  lime  over  the  contents 
of  the  vault  will  also  tend  materially  to  reduce  odors.  If  these 
simple  jjrovisions  are  strictly  carried  out,  odors  will  be  reduced 
to  a  minimum.  The  contents  of  such  a  privy  vault  should  not  be 
allowed  to  iill  higher  than  18  inches  below  the  top.  Before  this 
level  is  reached  the  contents  should  be  removed  in  water  tight 
containers  and  disposed  of  by  burial  in  trenches  at  a  depth  of 
not  less  than  one  foot  beneath  the  surface  of  the  ground  at  some 
isolated  })oint  at  least  200  feet  from  any  building;  or  a  new  pit 
should  be  dug  and  the  privy  building  removed  to  it.  In  the 
latter  case  the  old  pit  should  be  filled  to  the  surface  of  the  ground 
with  clean  earth  and  properly  protected  with  planks  and  the 
excavation  kept  full  until  the  contents  of  the  pit  have  become 
thoroughly  consolidated. 

The  next  type  of  privy  is  the  one  provided  with  removable 
receptacles.  This  type,  shown  in  Figure  2,  is  entirely  above 
ground  and  the  building  is  arranged  so  that  the  seat  forms 
part  of  the  closed  compartment  which  contains  the  receptacles. 
The  inside  of  the  privy  building  is  otherwise  arranged 
similarly  to  that  over  the  dug  vault  type  above  described. 
Beneath  the  openings  in  the  seats  are  placed  receptacles  for 
receiving  and  storing  the  excreta.  The  receptacle  should 
be  a  durable  metal  can,  preferably  a  heavy  galvanized  metal  ash 
can  with  a  handle  on  each  side.  A  very  convenient  size  is  known 
as  a  No.  3  ash  can,  15  inches  in  diameter  and  26  inches  high.  A 
privy  provided  with  two  such  cans  would  be  appropriate  for  a 
family  of  six  persons  and  would  ordinarily  require  cleaning  not 
oftener  than  once  a  month.  The  cans  are  removed  through  a 
hinged  door  in  the  back  of  the  building.  The  contents  should  be 
buried  in  an  excavation  at  some  remote  and  safe  point  and  be 
covered  with  at  least  18  inches  of  earth. 


Public  Health  Nursing 


69 


Ocreenecf 
Veniilaior 


Toilei- 


Fig.  I 
Privy  With|Vault 


YO  State  Department  of  Health 

In  one  corner  of  the  privy  should  be  placed  a  barrel  filled  with 
fresh  dry  earth  or  loam  and  provided  with  a  small  shovel.  A 
small  amount  of  this  earth  should  be  thrown  upon  the  contents  of 
cans  after  each  use.  Occasionally  chloride  of  lime  may  be 
sprinkled  into  the  cans.  Also  from  time  to  time  a  handful  of 
hoviix  may  be  sprinkled  into  the  cans  to  suppress  fly  breeding 
should  any  flies  succeed  in  getting  into  the  building.  In  order  to 
prevent  the  cans  from  becoming  too  full  the  seat  covers  should  be 
provided  with  locks  in  order  that  either  cover  may  be  locked  when 
necessary. 

This  latter  type  of  privy  is  considered  by  some  to  be  the  most 
sanitary,  for  it  has  a  maximum  of  advantages  and  a  minimum  of 
disadvantages.  It  is  particularly  applicable  for  summer  con- 
ditions where  freezing  is  not  a  factor,  and  is  generally  applicable 
for  tho  farm  since  there  is  no  pollution  of  the  soil  and  consequently 
no  contamination  of  the  well.  It  is  perfectly  permissible,  pro- 
vided all  precautions  are  observed,  to  locate  a  'privj  of  this  kind  at 
the  back  of  the  woodshed  or  other  convenient  place  near  the  house 
where  one  may  reach  it  under  shelter.  Caution,  however,  in  not 
locating  it  too  close  to  a  kitchen,  and  most  scrupulous  care  in  its 
maintenance,  must  be  obsei-ved. 

The  question  of  possible  freezing  of  the  contents  is  one  that  will 
require  careful  consideration  and  it  is  possible  that  at  most  coun- 
try places  the  outside  of  the  privy  may  be  protected  sufficiently  in 
winter  to  obviate  freezing  by  a  loose  covering  of  leaves  or  straw 
or  in  other  ways.  Another  suggestion  in  this  connection  is  the 
possibility  of  having  extra  cans  on  hand  to  replace  any  cans  that 
may  have  their  contents  frozen.  The  full  cans  can  be  conveniently 
stored  outside  at  somx  safe  and  remote  place  without  danger  in 
the  winter  time  and  until  a  thaw  comes,  at  which  time  advantage 
should  be  taken  of  the  weather  to  empty  the  cans.  It  must  be 
remembered  in  this  connection  that  trenches  should  be  dug  in 
advance  ready  to  receive  the  contents  when  the  cans  are  to  be 
emptied  during  the  winter  time. 

It  is  believed  that  these  two  types  of  privies,  the  dug  privy  and 
the  removable  container  type,  are  the  only  types  essential  for 
proper  sanitation  in  rural  districts;  the  dug  privy  affording  a 
convenient  and  economical  type  where  there  is  no  danger  of  pollu- 
tion of  a  water  supply;  the  removable  receptacle  type  affording 


Public  Health  ISTursing 


Yl 


Cori-ainQf 


6  o 


^ 

^ 


2"^-* 


Fig.  2 
Privy  Having  Removable  Container 


Y2  State  Department  of  Heai^th 

one  which  is  applicable  to  places  where  soil  pollution  is  not  per- 
missible. With  the  requirement  of  proper  location  fulfilled  and 
the  possibility  of  water  supply  pollution  avoided,  there  is  no 
reason  to  doubt  the  sanitary  propriety  of  either.  Indeed  there  is 
very  much  to  commend  the  ordinary  dug  privy,  properly  con- 
structed and  maintained,  where  this  type  is  permissible,  since  it 
is  essentially  the  most  economical  type  for  the  farmer  to  employ 
and  since  it  obviates  the  troublesome  and  potentially  dangerous 
feature  of  maintaining  removable  receptacles,  especially  where 
such  maintenance  is  delegated  to  possibly  ignorant  or  careless 
persons. 

For  the  country  home,  whether  the  farm,  the  isolated  cottage, 
or  even  the  house  in  a  sparsely  settled  hamlet  where  the  grounds 
are  comparatively  large  and  houses  well  separated,  the  two  types 
of  privy  shown  by  Figures  1  and  2  if  properly  constructed  and 
maintained  afford  means  for  disposal  of  human  excreta  which 
fulfill  all  necessary  requirements  of  sanitation  with  a  minimum 
of  cost  and  maximum  of  simplicity.  Other  types  such  as  the 
watertight  vault  involving  either  the  use  of  implements  for  clean- 
ing or  the  disposal  of  liquid  contents  into  the  soil  are,  for  the 
country  home,  either  unnecessarily  costly,  are  more  objectionable 
if  not  oflrensive  in  use  or  in  maintenance  with  the  facilities  ordi- 
narily available^  and  are  a  greater  menace  to  health. 

At  the  present  time  there  seems  to  be  a  general  and  increasing 
demand  in  the  country  districts  for  a  supply  of  running  water  in 
the  home  and  for  the  installation  of  inside  plumbing.  The  incon- 
venience of  pumping  water  from  a  well  and  of  using  the  outside 
privy  on  the  one  hand,  and  the  greater  simplicity  and  ease  with 
which  iTinning  water  may  now  be  introduced  under  pressure  into 
the  home  on  the  other  hand,  have  encouraged  the  well-to-do  farmer 
and  the  cottage  owner  to  insist  on  these  improvements. 

There  are  very  few  people  in  the  country,  however,  who  have  a 
clear  conception  of  the  responsibilities  which  the  water  carriage 
system  involves,  and  it  seems  rather  the  exception  than  the  rule 
to  find  one  who  does  not  think  it  permissible  to  run  the  drain  pipe 
from  his  toilet  and  bath  directly  into  some  stream,  used  perhaps 
by  others  below  for  a  water  supply ;  and  eminently  proper  to  do  so 
if  a  so-called  "^septic  tank  ''  is  installed  somewhere  along  the  sewer 
line. 


Public  Health  I^ursing  73 

A  number  of  important  conditions  should  therefore  be  im- 
pressed upon  those  who  would  install  these  conveniences  in  the 
country  home.  First,  the  liquid  wastes  or  sewage  from  an  ordi- 
nary household  are  from  100  to  300  times  as  large  in  amount  as 
the  concentrated  human  excreta  to  be  disposed  of  by  the  dry 
method.  Secondly,  sewage  is  just  as  dangerous  in  character,  so 
far  as  affecting  health,  as  are  the  concentrated  excreta,  and  in 
some  respects  even  more  so  on  account  of  the  ease  with  which  the 
large  quantity  of  liquid  may  become  disseminated  or  scattered 
through  the  soil  or  on  the  ground  or  into  a  stream.  Thirdly,  there 
are  serious  limitations  as  to  the  conditions  of  soil  and  topography 
under  which  the  installation  of  a  water  carriage  system  is  prac- 
ticable, or  at  least  economically  so,  for  where  the  soil  is  composed 
largely  of  clay  or  rock  this  method  if  practicable  at  all  is  very 
expensive. 

The  amount  of  sewage  to  be  disposed  of  from  a  family  of 
five  or  six  persons  in  a  country  home  provided  with  toilet,  bath, 
wash  basin  and  sink,  will  ordinarily  not  exceed  300  gallons  per 
day,  and  the  method  best  adapted  to  dispose  of  this  in  a  sanitary 
manner  will  depend  upon  the  character  of  the  soil,  and  the  topog- 
raphy and  availability  of  sites  with  reference  to  protection  of  the 
water  supply.  The  sewer  line  leading  from  the  house  should  be 
of  cast  iron  or  glared  tile  of  hub  and  spigot  pattern,  and  should 
be  laid  upon  as  uniform  a  slope  as  possible,  with  a  fall  of  at  least 
one-eighth  inch  or  pi^ferably  one-quarter  inch  to  the  foot,  and 
at  a  depth  of  not  less  than  two  feet  beneath  the  surface.  The 
disposal  plant  should  be  located  on  land  which  is  lower  than 
the  well  or  other  source  of  water  supply  or  at  least  not  on  the  line 
of  drainage  toward  it,  and  preferably  on  land  which  is  gently 
sloping  and  not  subject  to  saturation  or  flooding. 

The  method  of  disposal  to  be  selected  will  depend  largely  upon 
the  character  of  the  soil,  although  somewhat  upon  topography, 
especially  if  the  subsurface  irrigation  method  is  employed.  If  the 
soil  is  of  sand,  or  is  light  and  porous  in  texture,  the  ordinary 
leaching  cesspool,  such  as  is  shown  by  Figures  3  and  4,  will  gen- 
erally answer  all  requirements.  A  cesspool  suitable  for  a  family 
of  five  or  six  persons  may  be  simply  and  economically  constructed 
as  shown  in  Figure  3,  of  loose  broken  field  stone,  open  on  the 
bottom  and  provided  with  a  flat  stone  slab  or  heavy  oak  cover,  the 


74  State  Depaetment  of  Health 

whole  covered  over  with  earth  or  sod.  The  top  covering  may 
extend  slightly  above  the  natural  ground  surface  with  ground 
sloping  away  in  all  directions,  and  the  upper  few  inches  may  be 
cemented  in  order  to  deflect  and  prevent  the  entrance  of  surface 
water  during  rains.  A  vent  pipe  extending  above  the  ground  ter- 
minating in  a  cowl  or  bend  should  be  inserted  at  or  near  the  cess- 
pool in  order  to  prevent  back  pressure  of  air  on  the  plumbing  sys- 
tem. A  more  durable  covering  would  be  an  iron  manhole  frame 
with  perforated  cover  such  as  is  used  in  a  street  sewer. 

An  improved  type  of  leaching  cesspool  may  be  constructed  of 
hollow  building  brick  as  shown  by  Figure  4.  The  bricks  are  laid 
with  cement  joints,  the  hollow  portions  extending  radially  from 
the  center  of  the  cesspool,  thus  giving  opportunity  for  free  radial 
percolation  into  the  surrounding  soil.  If  the  soil  is  firm  a  foun- 
dation is  unnecessaiy,  otherwise  a  footing  course  is  provided. 

Where  the  soil  contains  a  large  percentage  of  clay  or  is  other- 
wise somewhat  impervious,  and  the  leaching  cesspool  alone  is 
insufficient  to  afford  the  necessary  percolating  area  to  prevent 
rapid  filling  and  overflowing,  relief  may  frequently  be  had  by  pro- 
viding additional  area  for  percolation.  This  is  conveniently 
accomplished  by  extending  a  few  short  lines  of  oj)en  jointed  sewoi" 
pipe  or  agricultural  tile  from  a  point  near  the  top  of  the  cesspool 
out  into  the  surrounding  soil.  These  few  lines  of  pipe  may  be 
considered  the  simplest  form  of  what  is  known  as  the  "  subsurface 
irrigation  system,"  a  system  which  may  be  elaborated  or  extended 
to  accommodate  as  many  as  100  persons,  although  experience  in 
this  State  indicates  that  it  is  rarely  practicable  to  extend  it  to 
serve  many  more  than  this  number. 

In  the  construction  of  a  subsurface  irrigation  system,  careful 
attention  must  be  given  to  details.  The  essential  parts  of  this 
system  are  the  settling  tank,  the  dosing  tank,  where  this  is  em- 
])loyod,  and  the  irrigtition  field.  The  simplest  form  is  that 
shown  by  Figure  4  comprising  the  ordinary  cesspool  and  a  few 
linos  of  tile  radiating  from  a  single  overflow  pipe,  the  latter  boinir 
usually  submerged  or  trapped  in  the  cesspool  by  the  use  of  a 
quarter  bend,  or  "  T,"  designed  to  prevent  floating  matter  from 
entering  the  overflow  pipe.  In  a  more  elaborate  system  a  concrete 
settling  or  septic  tank  will  be  necessary.  This  tank  is  usually  of 
rectangular  shape  and  the  larger  ones  are  preferably  divided  into 


Public  Health  Nursing 


75 


76  State  Dbpaetment  of  Health 

two  compartments  by  a  partition  wall  for  convenience  of  cleaning. 
A  tank  4  feet  wide,  4  feet  deep  and  6  feet  long,  would  have  ample 
capacity  for  a  family  of  6  or  8  persons.  For  additional  numbers 
of  persons  the  dimensions  should  be  increased  proportionately.  A 
dosing  tank  provided  with  an  automatic  siphon  is  frequently  pro- 
vided also,  though  this  is  not  absolutely  necessary. 

Where  the  dosing  tank  is  used  it  is  customary  to  combine  it 
with  the  settling  tank  by  means  of  a  division  wall  as  shown  in 
Figure  5.  The  automatic  syphon  is  a  commercial  product,  varia- 
ble in  type,  and  is  obtainable  from  a  number  of  manufacturing 
concerns  dealing  in  sewerage  and  sewage  disposal  devices.  The 
size  to  be  selected  will  depend  on  the  number  of  persons  contribut- 
ing sewage,  but  ordinarily  a  2-inch  or  3-inch  siphon  will  be  suf- 
ficient. The  siphon  discharges  the  contents  of  the  dosing  tank 
intermittently  into  the  irrigation  system  whence  it  is  distributed 
by  percolation  into  the  soil  beneath,  where  it  becomes  purified  by 
filtration. 

The  irrigation  system  itself,  especially  one  of  the  more  exten- 
sive ones,  comprises  a  series  of  lines  of  3-inch  or  4-inch  agricul- 
tural tile  pipe  branching  from  one  or  more  main  distributing  lines 
of  larger  diameter  as  sliowai  in  Figure  5.  These  lines  of  pipe  are 
usually  laid  from  12  inches  to  15  inches  beneath  the  ground  sur- 
face and  not  closer  than  4  feet  apart.  All  pipes  are  laid  with 
open  joints,  i.  e.,  with  the  ends  barely  touching  and  with  the  upper 
half  of  the  circumference  covered  with  a  collar  or  strip  of  tar 
paper  to  prevent  silting  in  of  the  earth  above.  These  lines  of  pipe 
are  ordinarily  laid  on  a  very  slight  slope,  not  more  than  6  inches 
in  100  feet,  and  it  is  therefore  desirable  that  a  level  or  gently 
sloping  field  be  selected.  To  secure  these  slight  gradients  the 
different  pipe  lines  are  laid  approximately  along  contour  lines 
(i.  e.,  lines  having  the  same  elevation,  as  illustrated).  The  length 
of  pipe  necessary  for  any  system  will  depend  upon  the  character 
of  the  soil  and  the  number  of  persons  served.  No  definite  rule  can 
be  laid  down,  but  generally  speaking,  in  sandy  soil,  10  to  20  feet 
per  per:ion  will  usually  suffice;  in  light,  loamy  soil,  40  to  60  feet; 
in  clayey  soil  this  system  is  not  applicable  at  all  and  recourse  must 
then  be  had  to  some  such  system  as  artificial  sand  filtration. 

The  most  essential  precaution  to  be  observed  in  constructing 
the  irrigation  system,  neglect  of  which  has  been  the  cause  of  most 


Public  Health  Nuiising 


77 


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Fig.  5 

Showing  Arrangement  and  Details  of  Subsurface  Irrigation  System —Gentle 

Sloping  Ground 


78  State  Department  of  Health 

failures,  is  to  have  the  open  joints  properly  protected.  These 
joints  are  designed  to  peiinit  the  outflow  of  sewage  effluent  into  the 
soil,  but  if  they  are  not  properly  protected  they  may  permit  the 
adjacent  soil  to  wash  or  sift  in  through  them  and  cause  obstruc- 
tions, if  not  fill  up  the  pipe.  It  is  very  necessary,  therefore,  to 
have  the  top  of  each  joint  covered  as  shown  in  detail  in  Figure  5, 
preferably  with  a  strip  of  heavy  tar  paper  about  4  inches  wide  and 
extending  over  the  top  and  well  down  on  the  sides  of  each  joint, 
but  not  entirely  encircling  it. 

Another  important  detail  in  connection  with  this  system  is  the 
arrangement  of  the  different  lines  of  pipe  where  the  slope  of  the 
land  is  somewhat  steep.  One  system  is  to  have  a  main  distrib- 
uting line  run  down  the  steep  slope  and  the  branch  lines  lead  from 
it  along  level  contour  lines.  Another  and  perhaps  better  plan  is 
to  omit  the  main  distributing  pipe  altogether  and  lay  out  the 
entire  system  in  one  or  two  continuous  lines  with  a  series  of  short 
steep  and  long  gentle  slopes.  The  line  would  first  run  down  the 
steep  slope  to  the  next  lower  contour  then  turn  and  run  along  this 
contour  line  with  a  gentle  slope  to  the  opposite  end  of  the  field ; 
then  turn  a  right  angle  and  run  down  the  steep  slope  to  the  next 
lower  contour  and  so  on.  A  third  and  perhaps  the  best  plan  is  to 
have  the  different  lines  of  tile  each  provided  with  its  independent 
distributor,  each  distributor  leading  from  a  common  diverting 
manhole.  Each  line  thus  receives  its  independent  and  propor- 
tional share  of  the  dose,  and  there  is  thus  a  uniform  distribution 
over  the  entire  field  without  surcharging  at  any  point. 

There  are  a  number  of  methods  of  sewage  disposal  other  than 
the  ordinary  cesspool  and  subsurface  irrigation  system,  such  as 
sand  filtration,  contact  beds  and  sprinkling  filters;  but  while 
applicable  to  large  serwerage  systems  for  villages  and  cities,  they 
meet  the  requirement  of  the  country  home  for  these  methods  all 
(Icinjind  special  knowledgo  and  skill  to  constnict,  involve  the 
final  discbarge  of  an  effluent  into  some  watercourse,  and  to  be 
successful  need  not  only  more  intelligent  but  more  skilled  supei-- 
vision  that  is  ordinarily  available  at  the  country  home.  The 
ordinary  cesspool  or  a  series  of  leaching  cesspools  installed  with 
the  precaution  above  pointed  out  will  usually  meet  all  require- 
ments demanded  in  the  contry ;  and  where  the  cesspool  is  sufficient 
there  will  be  few  cases  indeed  where  the  subsurface  irrigation 


Public  Health  Nuesing 


79 


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Fig.  6 
Showing  Arrangements  and  Details  of  Subsurface  Irrigation  System  — 
Steep  Sloping  Ground 


80  State  Department  of  Health 

system  will  not  prove  adequate.  ]Sreither  of  these  methods  in- 
volves an  effluent  to  be  finally  disposed  of  into  some  watercourse, 
and  both  are  more  sanitary,  self-maintaining,  and,  when  properly 
installed,  require  less  attention  than  the  more  elaborate  methods 
applicable  to  village  and  city  conditions. 

Disposal  of  Sewage  of  Institution  and  Municipalities 

In  considering  the  disposal  of  sewage  of  institutions  and  munic- 
ipalities it  will  be  assumed  that  the  sewage  has  been  collected 
in  a  system  of  intercepting  and  outfall  sewers  which  conduct  it 
to  a  suitable  point  for  sewage  disposal.  In  order  to  understand  the 
methods  by  which  such  sewage  can  be  properly  disposed  of  it  will 
be  well  first  to  consider  the  composition  of  the  sewage  which  in 
American  communities  usually  contains  from  400  to  500  parts  per 
million  of  solid  ingredients,  this  being  equivalent  to  about  one^ 
twentieth  of  one  per  cent. 

Of  these  solids,  about  two-thirds  are  found  to  be  in  suspension 
and  about  one-third  in  solution.  Again,  of  the  suspended  solids 
about  two-thirds  are  organic  matter  and  one-third  mineral  matter ; 
while  of  the  dissolved  solids  about  one-third  is  organic  matter 
and  two-thirds  mineral  matter.  It  is  in  fact  this  small  amount 
of  organic  matter,  less  than  five  one-hundredths  of  1  per  cent, 
which  gives  to  this  class  of  sewage  its  objectionable  qualities  find 
renders  it  at  times  difficult  of  purification. 

When  sewage  of  this  character  is  discharged  upon  land,  or  into 
a  body  of  water,  it  becomes  objectionable,  usually  in  one  of  three 
ways.  It  may,  in  the  first  place,  become  objectionable  in  appear- 
ance, due  to  the  floating  or  fine  suspended  matters  present  in  the 
sewage.  These  matters  tend  to  form  unsightly  deposits  upon  the 
bed  and  banks  of  a  stream,  and  to  interfere  in  many  ways  with 
the  industrial  or  pleasure  purposes  for  which  a  stream  may  be 
used.  This  objectionable  feature,  while  affecting  mainly  the 
esthetic  quality  for  a  stream,  and  only  those  persons  or  industries 
that  actually  use  the  water,  does  not  in  itself  affect  public  health. 

In  the  second  place  sewage  may  become  offensive  as  a  I'osult 
of  a  diffusion  of  gases  resulting  when  decomposition  is  carried 
to  the  point  of  putrefaction.  Although  this  feature  affects  the 
comfort  of  those  living  along  or  in  the  vicinity  of  a  stream,  the 


Public  Health  Nursing  81 

most  careful  investigation  fails  to  reveal  that  it  has  any  serious 
effect  in  producing  specific  diseases. 

Finally,  sewage  may  become  objectionable  through  the  dan- 
gerous ingredients  contained  in  it,  which  affect  the  health  of 
human  beings.  These  are  the  pathogenic  or  disease-producing 
bacteria  frequently  present  in  the  sewage.  They  enter  it  from  a 
variety  of  sources  such,  for  instance,  as  from  human  discharges. 

Generally  speaking,  any  method  of  sewage  disposal  for  an  insti- 
tution or  small  community  must  have  for  its  object  the  fulfill- 
ment of  one  or  all  of  the  following  requirements,  viz.,  to  remove 
the  coarse  and  fine  suspended  matter,  to  prevent  offensiveness  to 
the  body  of  water  or  land  into  or  upon  which  the  sewage  is  dis- 
charged, and  to  render  harmless  the  disease  germs  contained  in 
the  sewage.  The  extent  to  which  these  requirements  must  be  ful- 
filled in  any  case  will  depend  upon  the  volume,  the  character  and 
the  uses  made  of  the  stream  into  which  the  sewage  is  to  be  dis- 
charged. Although  there  are  no  set  rules  that  can  be  strictly 
adhered  to,  the  following  generalizations  are  made  with  respect  to 
such  requirements: 

First,  where  a  stream  is  not  subsequently  used  for  a  public 
water  supply,  but  where  its  esthetic  or  industrial  qualities  are 
important,  and  where  the  volume  of  flow  is  so  large,  as  compared 
with  the  volume  of  sewage,  that  offensiveness  will  not  result,  it 
will  be  only  necessary  to  remove  the  suspended  or  floating  matters 
by  eflBcient  screening  or  settlement. 

Secondly,  where  a  stream  is  not  used  subsequently  for  a  public 
water  supply,  but  where  the  volume  of  sewage  discharged  into  it 
compared  with  the  volume  of  flow  is  so  large  that  offensive  odors 
may  arise^  it  will  be  necessary,  in  addition  to  the  removal  of  sus- 
pended matters,  to  remove  or  oxidize  the  organic  matter  in  the 
sewage.  This  can  only  be  done  by  means  of  sewage  purification 
and  the  effluents  under  these  conditions  must  be  what  is  termed 
stable,  i.  e.,  purified  to  such  a  degree  that  it  will  not  of  itself,  or 
when  discharged  into  the  stream,  subsequently  putrefy. 

Finally,  where  a  stream  is  to  be  subsequently  used  for  a  water 
supply  not  adequately  protected  by  water  purification  it  may  be 
necessary  to  remove  all  substances  from  the  sewage,  including  the 
bacteria. 


82  State  Department  of  Health 

Where  a  community  is  favorably  situated  with  reference  to  a 
large  body  of  flowing  water  the  method  of  dilution  becomes  a 
satisfactoiy  one.  If,  however,  it  is  not  so  favorably  situated  or 
if  the  sewage  must  enter  a  stream  or  river  which  is  subsequently 
used  as  a  source  of  water  supply,  or  if  it  is  discharged  into  tidal 
waters  in  proximity  to  oyster  beds  this  method  must  be  abandoned 
in  favor  of  some  method  of  artificial  purification. 

Of  these  artificial  methods  perhaps  none  is  more  effective  than 
that  of  filtration,  or  the  slow  percolation  of  the  sewage  through 
beds  of  porous  soil  or  sand.  This  method  has  been  used  for  more 
than  a  century.  It  is  in  fact  nature's  method  of  purifying  dirty 
water,  which  after  rains  flows  over  the  surface  of  the  ground, 
descends  slowly  through  the  pores  of  the  earth,  and  finally  issues 
as  pure  spring  water. 

This  method  of  filtration  has  been  very  thoroughly  studied  for 
many  years  in  this  countiy  and  abroad  and  it  is  now  possible  to 
foretell  within  narrow  limits  how  much  sewage  of  a  certain  com- 
position can  be  successfully  purified  when  the  quality  and  the  size 
of  the  sand  grains  are  known.  Generally  speaking,  an  acre  of 
good  effective  sand  can  be  so  arranged  as  to  purify  indefinitely 
the  sewage  of  about  1,000  persons.  If  the  sand  is  coarse  and 
deep,  or  the  sewage  has  received  some  preliminary  treatment  to 
remove  the  suspended  matters,  a  still  larger  amount  of  sewage  can 
be  treated.  If  the  sand  is  fine,  or  mixed  with  loam  or  clay,  this 
amount  must  be  correspondingly  decreased,  reaching  almost 
nothing  for  soils  composed  mostly  or  wholly  of  clay. 

Tt  is  usual  to  arrange  sewage  filters  in  beds  or  units  of  a 
definite  size  with  the  surface  nearly  level  to  insure  a  uniform 
distribution  of  the  sewage.  Beneath  the  surface  at  a  depth  of  a 
few  feet  is  laid  a  system  of  collecting  pipes  or  underdrains.  The 
sewage  is  applied  in  turn  to  each  of  the  beds,  and  after  percolatino 
slowly  through  them  is  collected  in  the  system  of  underdrains  and 
discharged  into  the  nearest  watercourse. 

When  beds  of  porous  material  are  not  available  or  land  is 
ex[)ensive  it  is  frequently  found  more  economical  to  purify  sewage 
by  some  other  method  than  sand  filtration.  Of  these  methods 
chemical  precipitation  has  been  satisfactorily  practiced  in  the 
past,  and  although  this  process  has  given  way  to  more  economical 
and  effective  ways  it  is  still  used  in  many  places. 


Public  Health  Nursing  83 

By  this  method  the  sewage  is  passed  tlirough  tanks  after  It  has 
been  treated  with  certain  chemicals  such  as  lime  or  salts  of 
alumina  and  iron.  The  sewage  may  be  passed  slowly  through  the 
tanks  at  a  uniform  low  velocity,  or  the  tanks  may  be  filled,  allowed 
to  stand  for  a  period  of  time  and  then  discharged.  In  either  case 
the  chemicals  unite  with  certain  constituents  in  the  sewage  and 
form  a  coagulum  which  settles  to  the  bottom  of  the  tanks,  carry- 
ing with  it  and  precipitating  upon  the  bottom  the  suspended  mat- 
ters in  the  sewage.  The  relatively  clear  effluent  is  then  passed  off 
and  discharged  into  the  nearest  watercourse  or  subjected  to  further 
treatment. 

This  method  of  disposal  at  the  present  time  is  not  considered  a 
complete  one  in  itself,  but  is  practiced  as  such  in  some  places  and 
is  frequently  employed  as  a  preliminary  treatment.  The  difficulty 
of  disposing  of  the  sludge,  the  high  cost  of  chemicals  and  the  low 
purification  effected  make  this  method,  however,  a  comparatively 
expensive  one,  and  its  field  of  usefulness  restricted  to  peculiar 
local  conditions  or  to  the  disposal  of  certain  classes  of  trade  wastes. 

Of  greater  utility  than  the  chemical  precipitation  tank  is  the 
so-called  septic  tank.  The  origin  of  this  appurtenance  in  sewage 
disposal  is  our  well-known  cesspool.  In  fact  the  septic  tank  may 
be  considered  nothing  more  than  a  large  cesspool,  scientifically 
constructed  and  operated,  so  that  the  highest  biological  efficiency 
is  attained.  If,  then,  through  a  long  and  narrow  tank  domestic 
sewage  is  allowed  to  pass,  certain  results  are  obtained  depending 
upon  the  rate  at  which  the  sewage  flows.  When  this  rate  is  rela- 
tively high,  i.  e.,  if  the  period  of  detention  in  the  tanks  is  less  than 
about  four  hours,  a  mere  settling  or  sedimentation  of  the  sewage 
results  —  a  merely  mechanical  result  with  no  appreciable  biologi- 
cal action.  When  this  rate  of  flow  is  lessened,  however,  and 
the  detention  period  increased  to  about  eight  hours,  entirely  dif- 
ferent results  are  secured.  Instead  of  mere  mechanic;il  sub- 
sid'nr-e  there  is  in  addition  a  bacterial  or  septic  action  which 
produces  marked  changes  in  the  organic  mntter. 

The  biological  processes  carried  on  in  the  septic  tank  are  rather 
complicated.  They  are  also  quite  variable  in  activity  depending 
upon  many  factors  such  as  the  composition  and  age  of  the  sewage, 
its  temperature,  the  period  of  detention  and  the  velocity  of  flow 


84  State  Department  of  Health 

through  the  tank.  The  process  may  be  briefly  described  as  one 
in  which  decomposition  is  allowed  to  continue  until  the  sewage 

putrefies.  The  bacteria,  working  under  anerobic  conditions,  are 
able  to  break  down  the  more  complex  and  unstable  organic  com- 
pouiidy  and  coiivort  tlieiii  into  simpler  and  more  stable  ones.  This 
conversion  results  in  a  liquefaction  of  portions  of  the  suspended 
organic  matters  and  a  liberation  of  certain  gases,  such  as  sul- 
phuretted hydrogen,  marsh  gas  and  ammonia.  The  portion  of  the 
suspended  organic  matters  not  liquefied  either  rises  to  the  surface 
to  form  a  scum  over  the  liquid  in  the  tank,  or  settles,  together  with 
the  mineral  suspended  matter  not  previously  removed  by  settling 
or  screening  to  the  bottom  of  the  tank  in  the  form  of  sludge. 
Tliis  sludge  must  be  removed  from  time  to  time  and  disposed  of 
by  special  treatment. 

The  septic  tank  thus  fulfills  a  two-fold  object,  removal  by 
subsidence  of  a  considerable  portion  of  the  suspended  organic 
and  mineral  matters  and  the  decomposition  and  liquefaction  of 
a  large  part  of  the  suspended  organic  matter.  The  organic  matter 
thus  converted  is  in  a  condition  which  many  believe  to  be  better 
suited  to  subsequent  oxidation  and  nitrification  than  is  the  case 
with  the  raw  sewage.  And  whatever  may  be  said  against  the  eco- 
nomic value  of  the  septic  tank,  there  is  little  question  but  that 
]>roperly  septicized  sewage  is  more  easily  treated  than  either  raw 
sewage  or  sewage  that  has  been  subjected  to  plain  or  chemical 
precipitation,  and  that  the  septic  tank  will  continue  to  be  a  useful 
preliminary  device  in  sewage  disposal  for  many  years  to  come. 

The  treatment  of  either  settled  or  septic  sewage  is  usually 
accomplished  by  means  of  sand  filtration,  previously  described, 
or  by  means  of  coarse  grained  or  rapid  filters.  Of  the  latter  class 
of  filters  there  are  two  general  types;  the  contact  bed  and  the 
sprinkling  filter.  Although  both  are  composed  of  the  same 
materials — a  mixture  of  coarse  stone,  gravel  or  coke  —  and  are 
usually  laid  out  in  beds  or  units,  their  construction  and  operation 
are  somewhat  different. 

The  contact  l)ed  is  uPually  constructed  as  a  tank  in  which  the 
filtering  material  of  graded  sizes  is  deposited  with  the  coarser 
material  at  the  bottom.  The  sewage  is  run  onto  the  bed  until  it  is 
full  and  is  allowed  to  stand  in  contact  with  the  filtering  material 


Public  Health  Nursing  85 

for  a  definite  period  of  time.  During  this  interval,  and  under  the 
conditions  of  an  ample  supply  of  oxygen,  the  organic  matter  is  rap- 
idly acted  upon  by  the  aei'obic  bacteria  until  it  is  oxidized  or 
nitrified,  i.  e.,  subjected  to  the  last  chemical  change  or  action  in 
the  process  of  decomposition.  At  the  expiration  of  this  time 
period,  ranging  usually  from  two  to  four  hours,  the  purified  liquid 
is  drained  from  the  bed  and  discharged  into  the  nearest  stream, 
or  subjected  to  further  treatment. 

With  the  sprinkling  iilter  the  constniction  is  almost  identical 
with  that  of  the  contact  bed,  except  that  the  walls  surrounding  t]:e 
filter  may  be  omitted.  The  sewage  is,  however,  applied  in  a  very 
different  way.  Instead  of  flooding  the  filtering  material  the 
sewage  is  distributed  through  nozzles  over  the  beds  in  the  form 
of  sprayed  and  allowed  to  percolate  through  them  to  the  under- 
drains  beneath.  In  this  way  a  better  opportunity  is  aiforded  for 
aeration  and  nitrification,  and  results  show  that  not  only  is  the 
bacterial  efficiency  of  the  sprinkling  filter  higher  than  that  of  the 
contact  bed,  but  that,  owing  to  the  better  opportunities  for  oxida- 
tion, a  larger  volume  of  sewage  can  be  purified  per  unit  volume  of 
filtering  material. 

The  effluents  from  both  contact  and  sprinkling  filters,  though 
stable  in  themselves,  and  generally  of  satisfactoiy  quality  to  be 
discharged  into  any  watercourse,  are,  however,  not  entirely  free 
from  suspended  matters.  Fine  and  sometimes  rather  coarse 
particles  of  the  film  or  coating  attached  to  the  stones  of  the  filters, 
which  form  harboring  places  for  the  bacteria  while  performing 
their  work  of  nitrification,  become  dislodged  and  are  carried  into 
the  effluent.  These  particles  are  mostly  stable,  inert  matter,  rela- 
tively coarse  and  henv}-  and  subside  quickly  when  the  velocity  of 
the  effluent  is  checked.  When  it  is  desirable  then  to  remove  this 
suspended  matter  and  to  secure  a  clear  effluent,  it  is  only  necessary 
to  pass  the  effluent  through  a  set  [ling  tank  of  moderate  size  and 
allow  the  suspended  matter  to  settle  out. 

Again,  we  find  that  the  effluents  from  these  rapid  filters  are  not 
entirely  free  from  bacteria  and  in  some  cases  they  show  a  very 
incomplete  removal.  These  bacteria  are  in  a  large  measure  car- 
ried into  the  effluent  along  with  the  other  suspended  matters  just 
described,  and  are  probably  of  the  harmless  variety  of  nitrifying 


86  State  Department  of  Health 

bacteria  that  have  developed  either  in  the  septic  tank  or  in  the 
filter.  It  is  also  probable  that  many  of  them  are  of  the  pathogenic 
species  originally  present  in  the  sewage,  so  that  there  may  be 
cases  where  it  is  desirable  or  imperative  to  remove  not  only  the 
suspended  matter  but  also  the  Ijacteria.  When  this  standard  of 
purity  is  demanded  it  becomes  necessary  to  resort  to  supplemen- 
tary treatment  either  along  lines  practiced  for  the  purification  of 
water,  such  as  mechanical  or  slow  sand  filtration,  or  by  some 
method  of  sterilization. 

The  disinfection  of  a  sewage  effluent  or  of  raw  sewage  is  gen- 
erally accomplished  by  the  application  of  chloride  of  lime  or  chlo- 
rine gas.  In  either  case  after  the  disinfectant  is  applied  the 
sewage  or  effluent  is  usually  passed  through  a  small  detention 
tank  holding  from  10  to  20  minutes  flow  in  order  to  afford  oppor- 
tunity and  time  for  the  chemical  to  act  upon  and  kill  the  bacteria. 
If  chloride  of  lime  is  used  it  is  first  made  into  a  solution  and  the 
solution  is  applied  to  the  sewage  uniformly  in  proportion  to  the 
flow.  If  chlorine  gas  is  used  it  is  usually  applied  directly  to  the 
sewage  or  effluent  through  a  diffuser  from  cylinders  of  chlorine 
which  contain  the  gas  in  liquid  form  under  pressure.  In  applying 
the  gas  it  is  generally  passed  through  a  regulating  device  which 
automatically  permits  of  its  application  at  unifonn  rates  pro- 
portional to  the  flow  of  the  sewage.  Only  small  amounts  are 
required  for  disinfection,  ranging  from  5  to  25  parts  of  free 
chlorine  per  million  parts  by  weight  of  sewage  or  sewage  effluent, 
the  larger  amounts  being  used  for  raw  sewage  and  the  smaller  for 
sewage  effluents. 


Public  Health  Nursing  87 


CHAPTER  VI 
Control  of  Flies,  Mosquitoes  Other  Insects  and  Vermin 

It  has  been  proved  by  scientific  experiments  that  flies  are  active 
factors  in  the  transmission  of  disease;  that  the  female  anopheles 
mosquito  is  an  essential  factor  for  the  spread  of  malaria;  that 
bubonic  plague  is  a  chronic  disease  in  rats,  the  internal  parasite  of 
which  is  conveyed  to  humans  through  the  bite  of  the  flea;  and  that 
the  body  louse  is  the  intermediary  host  in  the  transmission  of 
typhus  fever.  The  control  of  the  fly,  mosquito  and  rat  through 
attack  upon  their  breeding  places  and  food  supply,  and  measures 
for  the  complete  destruction  of  the  louse,  have  thus  become  an 
integral  part  of  any  comprehensive  sanitary  program  which  may 
fall  within  the  province  of  the  public  health  nurse. 

The  fly.  Studies  of  typhoid  fever  in  the  United  States  Army 
camps  in  1898,  and  later  in  the  city  of  Jacksonville,  and  the  study 
of  diarrheal  diseases  of  infants  made  in  New  York  City  in  1915, 
have  clearly  demonstrated  that  the  presence  of  the  fly  with  access 
to  human  excrement  and  other  discharges  or  food  supplies 
increases  the  prevalence  of  these  diseases.  The  campaign  for  the 
control  of  the  fly  involves  (a)  prevention  of  fly  breeding  and 
(b)  prevention  of  flies  having  access  to  human  beings  and  to  their 
food. 

In  the  supervision  of  communicable  disease,  or  in  a  sanitary 
survey  looking  to  prevent  conditions  which  are  factors  in  causing 
disease,  the  nurse  may  be  called  upon  to  make  a  survey  of  all 
privies  in  the  community,  noting  overflow,  failure  to  screen  or 
other  insanitary  conditions  which  permit  access  of  flies  to  the 
excrement,  and  of  places  where  are  found  manure  or  other  refuse 
matter  in  which  flies  are  wont  to  breed. 

The  practical  methods  of  controlling  the  spread  of  disease  by 
flies  fall  under  four  main  headings: 

(1)  The  prevention  of  the  breeding  of  the  fly  by  the  elimina- 
tion of  its  breeding  places.  This  requires  the  proper  care  of  stable 
manure  and  the  removal  or  disinfection  of  all  decomposing  refuse 
such  as  garbage,  wet  papers  and  rubbish  of  all  sorts.  The  treat- 
ment of  manure  and  other  refuse  with  chemical  disinfectants  for 


88  State  Department  of  Health 

the  prevention  of  fly  breeding  is  a  new  development  of  the  last 
few  years  and  progress  has  been  rapid.  Borax  has  proved  much 
more  satisfactoiy  than  the  substances  previously  used,  and  now 
the  United  States  Department  of  Agriculture  recommends  helle- 
bore as  even  better  than  borax. 

(2)  The  control  of  breeding  places  must  usually  be  supple- 
mented by  the  trapping  of  adult  flies.  A  simple  and  effective  trap 
may  be  made  from  a  grocery  box  by  substituting  wire  netting  for 
the  top  and  two  sides,  cutting  a  round  hole  in  the  bottomand  insert- 
ing in  it  a  wire  cone  with  an  eight  inch  opening  at  the  bottom  and  a 
half-inch  opening  at  the  top.  A  suitable  bait,  a  fish  head  for 
example,  may  be  placed  under  the  box  and  the  flies  which  seek  it 
will  fly  from  it  up  toward  the  light  and  through  the  small  top 
opening  into  the  box.  Dead  flies  may  be  shaken  out  through  a 
small  opening  ordinarily  closed  by  a  sliding  door. 

(3)  The  measures  suggested  above  will  greatly  reduce  the 
number  of  tlies  but  are  not  likely  to  do  away  with  them  entirely. 
As  long  as  any  flies  at  all  are  about  it  is  essential  to  keep  them 
from  human  excrement  where  they  may  pick  up  the  germs  of 
typhoid  fever  and  similar  diseases.  Privy  vaults  should  there- 
fore be  most  carefully  constructed  to  exclude  flies.  The  dis- 
charges should  be  received  in  a  tight  receptacle  and  all  openings 
for  ventilation,  etc.,  should  be  screened  with  wire  or  cloth  mos- 
quito netting  and  all  cracks  in  the  walls  or  openings  under  the 
bottom  should  be  closed. 

(4)  Finally,  the  doors  and  windows  of  houses  should  be 
screened,  especially  in  the  kitchen  and  dining  room,  in  the  nursery 
and  any  room  in  which  there  is  a  case  of  sickness.  Care  should  be 
taken  to  see  that  the  screens  fit  accurately  and  that  they  are 
always  in  place  and  that  screen  doors  are  not  left  ajar  or  kept 
open.  If  wire  screen  can  not  be  afforded  flies  may  be  kept  out  by 
cotton  mosquito  netting  tacked  over  the  windows.  Flies  that  do 
get  into  the  house  should  be  killed  or  should  be  caught  in  a  saucer 
of  water  containing  formalin,  sugar  and  water. 

Fish  and  meat  markets  and  restaurant  kitchens  should  be 
equipped  with  fly  traps.  Ten  thousand  flies  have  been  caught  in 
throe  days  at  such  places.  If  there  are  clouds  of  flies  in  the 
market  or  the  dining  rooms  or  if  foods  exposed  for  sale  are  unpr> 


Public  Health  Cursing  89 

tected  against  flies,  the  wise  customer  will  go  elsewhere  with  his 
patronage. 

The  anopheles  mosquito.  The  presence  of  the  female  anopheles 
mosquito  is  requisite  for  the  spread  of  malaria.  To  determine  if 
a  given  case  is  one  of  malaria  it  is  necessary  to  submit  a  smear  of 
the  patient's  blood  for  laboratory  examination  for  the  demonstra- 
tion of  the  presence  or  absence  of  the  malarial  parasite. 

The  practical  control  of  malaria  consists  in  destruction  of 
breeding  places  of  the  anopheles  mosquito,  the  capture  of  the  adult 
insect,  thoroughly  screening  the  sick  person  from  a  visit  of  the 
female  anopheles  mosquito  and  medical  treatment  of  the  malarial 
patient. 

In  order  to  determine  if  the  larvae  of  the  anopheles  are  present 
in  a  locality  the  nurse  may  be  required  to  collect  specimens  of 
water  from  places  where  they  might  be  expected  to  breed. 
For  this  work  she  should  be  provided  with  a  canvas  or  other  bag 
or  satchel,  a  small  dipper  with  long  handle,  a  teaspoon,  and  several 
small  vials  with  stoppers.  The  larvae  are  found  in  the  sedges  and 
other  vegetation  bordering  ponds,  puddles,  ditches  and  streams, 
generally  in  clean,  clear  water,  sometimes  in  streams  with  con- 
siderable current,  rarely  in  cans  and  rain  barrels  unless  some  vege- 
tation is  present,  rarely  in  sewage-polluted  streams,  but  often  in 
hollows  in  logs,  footprints  of  animals  in  the  fields,  and  even  in 
cups  and  basins  formed  by  large  broad  leaves  and  pitcher-shaped 
plants.  The  ova  of  the  anopheles  mosquito  float  on  the  surface  of 
the  water  and  are  grouped  in  a  pattern  not  unlike  the  meshes  of  a 
fish-net;  the  ova  of  the  culex  variety  also  float,  but  they  are 
grouped  together  in  the  form  of  a  little  raft.  The  larva  of  the 
anopheles  is  much  the  most  sensitive  of  the  mosquito  larvae,  hiding 
when  disturbed  by  sounds  or  even  shadows,  but  coming  to  the 
surface  for  air.  It  may  be  distinguished  from  the  larva  of  the 
culex  in  that  it  floats  horizontally  to  and  just  under  the  surface  of 
the  water,  while  the  culex  larva  suspends  itself  at  an  angle  to  the 
surface,  tail  up  and  head  dovm,  into  the  water.  It  requires  from 
9  to  16  days  for  the  transformation  from  ovum  to  mosquito,  and 
somewhat  longer  if  the  weather  is  cool.  Some  practice  and  much 
patience  will  be  needed  before  the  nurse  will  become  skilled  in 
collecting  larvae. 


90  State  Department  of  Health 

For  sociirijig  specimens  and  for  capture  of  the  adult  mosquito 
several  large  test  tubes  with  rubber  bands  soaked  in  chloroform  in 
the  bottom  of  the  tube  should  be  used ;  the  mosquito  is  trapped  in 
the  tube,  the  chloroform  quickly  acts  and  a  pledget  of  cotton 
secures  her  for  examination.  The  anopheles  mosquito  may  be 
identified  while  resting,  by  the  fact  that  the  body  from  head  to  tail 
is  in  a  straight  line  and  at  an  angle  of  about  forty  degrees  to  the 
surface  on  which  it  is  resting.  The  culex  mosquito  has  a  bend  or 
flexion  at  the  thorax  which  causes  the  head  to  point  toward  the 
surface  on  which  it  is  resting,  the  body  being  almost  parallel 
thereto. 

To  destroy  its  breeding  places,  weeds,  sedges  and  grass  should 
be  cut  and  cleared  from  all  possible  haunts  of  the  mosquito.  It 
may  be  found  necessary  to  burn  out  the  vegetation  bordering  the 
puddles  and  ditches.  The  ponds  and  streams  should  be  stocked 
with  small  minnows  which  eat  the  larvae  and  the  surface  of  the 
water  should  be  oiled.  For  this  latter  purpose  Chapin  estimates 
the  required  amount  to  be  an  ounce  of  crude  petroleum  to  15 
square  feet  of  surface,  the  oiling  to  be  repeated  regularly  every  7  to 
l-i  days  during  the  breeding  season.  A  lamp  wick  or  piece  of  waste 
loosely  placed  in  a  hole  in  a  keg  of  oil  will  make  a  satisfactory 
applicator,  which  may  be  managed  from  a  small  boat.  For 
puddles,  ditches  and  trenches,  it  will  be  necessary  to  use  a  spray. 
Systematic  search  of  houses  for  the  adult  mosquito  should  be 
made,  as  the  insects  hide  in  closets,  in  the  cellar  and  under  the 
beds.  The  female  anopheles  which  has  never  had  access  to  a 
person  with  malaria  is  unable  to  communicate  the  disease. 

When  the  anopheles  mosquito  is  present,  all  carriers  and  cases 
of  malaria  should  be  carefully  screened  in  such  manner  that  no 
mosquito  can  bite  them.  In  Panama  it  was  found  that  the  flight 
of  the  anopheles  at  times  exceeds  one  mile  from  the  breeding  place. 

The  rat.  Since  the  report  by  the  Indian  Plague  Commission, 
the  work  of  which  was  begun  in  1905,  it  has  been  recognized  that, 
as  a  factor  in  international  sanitation,  destruction  of  the  rat 
should  receive  general  attention.  In  the  State  of  IS^ew  York  under 
present  conditions  the  nurse's  part  will  consist  in  teaching,  where 
necessary,  the  method  of  extermination  to  be  used  by  householders. 
In  cities,  where  wharves  and  large  grain  elevators  exist,  rats 
become  very  numerous.     If  the  food  supply  is  removed  the  rats 


Public  Health  Nursing  91 

will  migrate;  therefore,  the  first  essential  is  that  all  refuse  which 
may  serve  as  food  shall  be  promptly  placed  in  metal  containers 
with  tightly  fitting  covers,  and  that  it  shall  not  be  spilled  on  the 
floor  or  ground.  If  rats  are  present,  all  foods  should  be  kept  in 
rat-proof  closets  or  storerooms.  Concrete,  metal  and  stout  close 
mesh  wire  screens  should  be  used  for  the  purpose.  Careless 
handling  and  spilling  of  food  must  be  avoided.  Cleaning 
up  the  premises,  removal  of  rubbish,  sanitary  disposal  of  garbage, 
and  trapping  the  rats,  in  addition  to  the  other  measures  named, 
will  rid  the  place  of  their  presence.*  For  vessels  lying  at  a  rat- 
infested  dock  the  hawsers  which  tie  the  boat  to  the  shore  should 
be  freshly  tarred  and  protected  with  inverted  cones.  Gang  planks 
should  be  lifted  when  not  in  use.  If  rats  are  in  a  vessel  it  should 
be  disinfected  with  sulphur  dioxide  and  the  dead  animals  sub- 
sequently removed  and  destroyed,  care  being  taken  not  to  touch  the 
animals  with  unprotected  hands. f 

The  louse.  Three  species  of  lice  are  sometimes  found  upon  man : 
{l)Pediculus  capitis  or  humanus,  the  head  louse,  the  ova  of  which 
are  attached  to  the  hair  and  known  as  nits;  (2)  Pediculus  vesti- 
menti  or  corporis,  the  clothes  or  body  louse,  which  lives  in  the 
clothing  and  sucks  the  blood  chiefly  of  the  neck,  back  and  abdo- 
men; and  (3)  Pediculus  pubis  or  crab  louse,  found  in  the  parts  of 
the  body  covered  with  short  hairs. 

Both  the  head  and  body  lice  may  transmit  disease.  They  are 
known  to  be  the  intermediary  host  in  typhus  fever,  and  recently  it 
has  been  demonstrated  that  the  so-called  "  trench  fever  "  of  the 
soldiers  in  Europe  is  conveyed  by  the  louse. 

.  The  prevention  of  lousiness  is  almost  entirely  a  matter  of  per- 
sonal cleanliness.  The  most  scrupulous  individuals,  however,  may 
become  infested.  Lice  may  be  passed  directly  from  one  person  to 
another,  or  occasionally  may  be  carried  by  clothes  or  other 
means.     Beds  in  hotels  and  sleeping  cars  are  sources  of  infestation. 

To  destroy  head  lice.  Saturate  the  hair  with  crude  petroleum 
or  kerosene,  being  careful  of  proximity  to  fire.  Tie  up  the  head 
for  several  hours,  after  which  saturate  with  vinegar  and  again  tie 
up  the  hair  for  a  short  time  in  a  bathing  cap  or  cloth  turban. 

*  Cats  are  also  helpful;  while  they  do  not  destroy  all  the  rats,  they  aid  in 
driving  them  off  the  premises. 

t  See,  The  Rat  and  Its  Relation  to  Health.  Issued  by  the  U.  S.  Public 
Health  Service. 


92  State  Department  of  Health 

Wash  and  dry  the  hair ;  remove  the  dead  insects  with  a  fine  tooth 
comb  and  the  eggs  with  the  fingers.  Examine  the  head  daily  and 
use  a  fine  tooth  comb.  The  petroleum  must  be  used  every  second 
day  in  bad  cases.  To  be  efficacious  the  heads  of  other  members  of 
the  family  and  of  associates  must  receive  suitable  attention  and 
treatment.    All  school  children  should  learn  to  use  preventive  care. 

To  destroy  body  lice.  Bathe  frequently  with  warm  water  and 
soap,  boil  infested  garments,  burn  filthy  bedding  and  clothing 
which  can  not  be  boiled,  clean  and  renovate  beds  and  infested 
quarters.  Studies  recently  made  under  the  United  States  Public 
Health  Service  have  resulted  in  the  adoption  of  a  method  of  treat- 
ing persons  by  means  of  a  gasoline  soap  spray  and  shower  bath, 
and  of  treating  clothing  and  baggage  with  a  vacuum  hydrocyanic 
gas  process.  Both  lice  and  nits  are  killed  by  heating  to  158°  F.  for 
ten  minutes.  Dry  heat  is  more  effective  than  moist  heat.  Per- 
haps the  best  substance  to  anoint  the  skin  with  is  an  ointment  made 
of  5  per  cent  naphthalin  in  petroleum. 

The  bed  bug.  This  insect  has  become  a  true  domesticated  ani- 
mal and  has  accommodated  itself  well  to  the  environments  of 
human  habitations.  It  has  no  wings  but  a  very  flat  body  which 
enables  it  to  hide  in  the  narrowest  cracks  and  crevices  of  beds  and 
walls.  It  is  nocturnal  in  its  habits.  The  presence  of  bed  bugs  in 
a  house  is  not  necessarily  an  indication  of  uncleanliness  or  care- 
lessness. They  are  apt  to  get  into  trunks  of  travelers  or  may  be 
introduced  in  the  homes  upon  the  clothing  of  servants,  workmen, 
etc.  They  often  migrate  from  one  house  to  another.  They  thrive 
particularly  in  old  houses  which  are  full  of  cracks  and  places  in 
which  they  can  conceal  themselves. 

Bed  bugs  are  suspected  hosts  and  carriers  of  disease.  The 
most  effective  way  of  eradicating  bed  bugs  is  by  a  liberal  applica- 
tion of  gasoline,  kerosene,  or  any  other  of  the  petroleum  oils. 
Gasoline  is  the  best  remedy  when  no  danger  from  explosion  from 
an  open  fire  is  present.  It  should  be  sprayed  into  crevices  of  the 
wood  or  metal,  folds  and  cracks  of  the  mattress,  furniture  and 
walls.  In  treating  metal  and  hard  wood,  sometimes  gasoline  or 
alcohol  may  be  poured  in  small  amounts  into  the  cracks  and  then 
ignited,  but  this  should  never  be  done  except  by  someone  with  suffi- 
cient care  and  judgment  to  prevent  danger  from  fire.     At  times 


Public  Health  Nursing  93 

furniture  is  so  infested  with  the  bugs  that  it  will  be  necessary  to 
destroy  it  to  get  rid  of  the  pests.  At  other  times  thorough  renova- 
tion of  the  premises  is  sufficient. 

The  itch  mite.  All  children  who  make  a  practice  of  scratching 
themselves  or  have  an  irritation  of  the  skin  should  be  examined  for 
scabies  (the  itch  mite).  A  clean  body  and  clean  clothes  are  the 
preventive  measures.  A  daily  bath  in  warm  water  and  soap,  and 
once  daily  boiling  the  garments  worn  next  to  the  skin,  are  impera- 
tive in  the  treatment  of  scabies.  A  sulphur  or  other  ointment,  if 
prescribed  by  a  physician  in  charge,  may  be  applied  after  the  bath. 
It  is  important  that  all  infested  members  of  the  family  be  treated 
until  cured,  else  the  disease  is  passed  back  and  forth  from  one  to 
another.  Interchange  of  body  linen  among  children  and  others 
must  be  prohibited  unless  the  garments  are  first  boiled.  The 
infested  person  should  not  share  the  crib,  pillow  and  bed  of  one 
not  having  the  disease.  Unless  strict  obedience  to  instructions  and 
perseverance  are  secured,  cases  will  prove  obstinate. 


94  State  Department  of  Health 

CHAPTER   VII 
The  Nurse  and  Communicable  Diseases 

Most  large  cities  now  employ  one  or  more  nurses  who,  working 
under  the  direction  of  the  health  officer,  devote  their  entire  time 
to  assisting  in  the  control  of  communicable  diseases  other  than 
tuberculosis.  In  smaller  communities  the  same  nurse  may  in 
addition  devote  time  intermittently  to  other  important  activities 
including  child  welfare,  school  work  and  cai^e  of  tuberculosis,  the 
amount  of  time  given  to  each  depending  on  season,  occurrence  of 
communicable  disease  outbreaks  and  other  local  conditions. 

There  are  open  to  health  officials  two  distinct  courses  of  pro- 
cedure with  reference  to  communicable  diseases;  the  first,  that  of 
attemjjting  to  control  epidemics,  the  other  the  more  modern  and 
effective  method,  that  of  preventing  them.  The  prevention  of 
outbreaks  requires  initiative,  constant  vigilance,  and  an  adequate 
force  of  trained  workers  who  are  kept  informed  as  to  the  latest 
advances  in  knowledge  of  methods  and  procedure.  The  most 
effective  aid  to  a  competent  health  officer  in  this  work  is  an  active, 
experienced  and  tactful  public  health  nurse. 

The  nurse  may  be  called  upon  to  perform  any  or  all  of  several 
duties  along  this  line.  She  may  seek  unreported  or  undiscovered 
cases ;  visit  rq^orted  cases  and  contacts,  secure  necessary  data  for 
record  or  tabulation  and  study,  give  instructions  to  attendants  or 
members  of  the  family  regarding  care  of  the  patient,  disposal  of 
discharges  and  other  necessai*y  precautions;  arrange  for  care  and 
relief  of  needy  patients  and  families  or  supervise  quai-antiue.  She 
should  not  be  authorized,  for  obvious  reasons,  to  pass  upon  or  con- 
firm diagnoses  of  attending  physicians.  In  the  absence  of  a  school 
nurse  she  may  make  regular  inspections  of  school  children  when 
communicable  diseases  are  prevailing  and  visit  absentees  in  their 
homes.  Whatever  her  duties,  she  should  maintain  a  systematic 
record  of  work  performed. 

Whatever  her  other  qualifications  the  public  health  nurse  must 
cultivate  diplomacy.  Coming  in  contact  in  an  official  capacity, 
as    she  does,  with  public    officials,  physicians    and    members    of 


Public  Health  ISTursing  95 

families  in  every  walk  of  life,  success  in  her  work  will  depend 
in  large  measure  upon  her  ability  to  perform  her  duties  and  secure 
compliance  with  her  instructions  with  a  minimum  of  friction. 

Reporting  Communicable  Diseases 

CommunicaLle  diseases  can  be  effectively  controlled  only  if 
local  health  authorities  have  immediate  knowledge  of  the  existence 
and  location  of  each  case.  Physicians  are  required  by  the  Xew 
York  State  Sanitary  Code  to  report  immediately  to  local  health 
officers  all  cases  of  communicable  diseases,  excepting  syphilis, 
gonorrhea  and  chancroid,  attended  by  them.  When  no  physician 
is  in  attendance  upon  a  case,  a  report  is  required  from  the  head 
of  a  school  or  household,  or  the  person  in  charge  of  a  hotel,  board- 
ing or  lodging  house,  in  which  the  case  may  be.  Visiting  or  public 
health  nurses,  persons  in  charge  of  labor  or  other  camps,  and  of 
vessels,  are  required  to  report  under  certain  conditions. 

It  is  particularly  essential  that  public  health  nurses  in  New 
York  State  be  familiar  with  the  requirements  of  the  State  Sanitary 
Code  relative  to  the  reporting  of  communicable  diseases.  For  this 
reason  there  is  presented  below  a  list  of  these  communicable  dis- 
eases together  with  a  table,  prepared  for  the  department's  manual, 
"  The  Prevention  and  Control  of  Communicable  Diseases,"  show- 
ing by  whom,  to  whom,  and  under  what  conditions,  reports  are 
required.  Ts^urses  employed  in  municipal  work  should  bear  in 
mind  the  fact  that  local  health  boards  have  authority,  under  the 
Public  Health  Law,  to  make  further  regulations  not  inconsistent 
with  the  provisions  of  the  Sanitary  Code,  and  should  be  familiar 
with  existing  regulations  in  their  own  municipalities. 

Diseases  declared  to  be  communicable  by  regulation  1,  chap- 
ter TT,  of  the  Sanitai-y  Code: 
A.  Aiitlu-ax 

Chickenpox 

Cholera,  Asiatic 

Diphtheria  (membranous  croup) 

Dvsentei-y,  amoebic  and  bacillarv 


96  State  Department  of  Health 

Epidemic  cerebrospinal  meningitis 

Epidemic  oi^  streptococcus  (septic)  sore  throat 

Epidemic  influenza 

German  measles 

Glanders 


Mumps 

Para-typhoid  fever 
Plague 
Pneumonia 

a.  acute  lobar 

b.  bronchial  or  lobular 

Poliomyelitis,  acute  anterior   (infantile  paralysis) 
Puerperal  septicaemia 
Rabies 
Scarlet  fever 
Smallpox 
Tetanus 
Trachoma 
Tuberculosis 
Typhoid  fever 
Typhus  fever 
Whooping  cough 
B.    Syphilis 
Gonorrhoea 
Chancroid 

Ophthalmia  neonatorum  (suppurative  conjunctivitis  of  the 
newborn) 


Public  Health  JSTursing 


97 


Reports  Kequiked 


Persons  of  whom 
reports  are 
required 

When? 

What? 

To  whom? 

By  what  law  or 
regulation? 

Within   twenty-four 

Persons  affected   with  com- 
municable    disease     other 

Health  officer 

Code,    chapter    II, 

reg  2  *  . 

cases  are  seen. 

than    gonorrhea,    syphilis 
and  chancroid. 

Physicians 

Immediately 

Cases  of  cholera,  diphtheria, 
dysentery,  epidemic  menin- 
gitis,   septic    sore    throat, 
typhoid  and  paratyphoid, 
scarlet  fever,  poliomyelitis, 
or  smallpox  on  dairy  farm. 

Health  officer 

Regulation  8 

Heads  of  hospitals, 

Immediately     upon 

Cases  of  communicable  dis- 

Health officer 

Regulation  3 

dispensaries     and 

development      of 

eases    in    persons    under 

other  institutions. 

disease  or  admis- 

their  charge. 

Medical     inspectors 

Immediately 

Cases  of  (certain)  communi- 

Health officer 

Educ.   Law,  article 

of  schools. 

cable    diseases    in    school 
cliildren. 

XX-A,  section  575 

Persons  in  charge  of 

Immediately 

Children  who  appear  to  be 

Health  officer 

Regulation  4. 

affected  with  disease  pre- 

pals, etc.). 

sumably  communicable. 

School  teachers .... 

Immediately 

Children  in  their  charge  who 
appear  to  be  affected  with 
diseases  presumably   com- 
municable. 

Principal  or  person 
in    charge    of 
school. 

Regulation  4. 

Attendance  (truant) 

Immediately 

Children  apparently  affected 

Principal  or  person 

Special     regulation, 

with     communicable     dis- 

in    charge    of 

state  departments 

school. 

of  education  and 

tion  of  liealth  officer. 

health. 

Heads  of  households, 

Immediately 

Persons  in  sueh  places  who 
appear  to  be  affected  with 

Health  officer 

Regulatioa  5. 

proprietors         or 

keepers  of  hotels, 

disease    presumably    com- 

boarding or  lodg- 

municable. 

ing  houses. 

Owners  or  persons  in 

Immediately     when 

Any  person  affected  with  a 
disease    presumably    com- 

Health officer 

Regulation  9. 

no  physician  is  in 

farms. 

attendance. 

municable  employed  or  re- 

Nurses  and  persons 

Immetfiately 

Any    person    affected    with 

Health  officer 

Regulation  6. 

disease    presumably    com- 

municable who,  by  reason 
of  danger  to  others,  seems 
to  require  attention  of  pub- 
lic health  authorities. 

Persons  in  charge  of 

Immediately 

Persons    on    vessel    affected 

To  health  officer  of 

Regulation  7. 

vessel  lying  with- 

with   disease    presumably 

such  municipality 

in  jurisdiction  of 

communicable. 

as  commissioner  of 

State. 

health  may  desig- 
nate. 

Immediately 

Deaths  from   communicable 
diseases. 

Health  officer 

Public  Health  Law, 

ch.  559,  see.  320, 

San.   Code,  regu- 

lation 43-b,  chap. 
Public  Health  Law, 

Health  ofucers 

Immediately 

Cases  of  communicable  dis- 

State department  of 

ease  reported  as  above. 

health. 

art.  HI,  sec.  25. 

Health  officers 

Immediately 

Cases   of   certain   communi- 
cable   diseases    on    dairy 
farms. 

State  department  of 
health     by     tele- 
phone    or     tele- 
graph. 

Regulation  8. 

'  Regulations  referred  to  are  in  chapter  II  of  the  Sanitary  Code  unless  otherwise  specified. 

4 


98  State  Depart^iext  of  Health 

Eegiilation  ^i,  chapter  II  of  the  Sanitaiy  Code,  which  refers 
to  the  reporting  of  cases  of  certain  diseases  occurring  upon  dairy 
farms,  is  especially  important  because  of  the  danger  of  transmis- 
sion of  the  infective  agents  of  these  diseases  to  large  numbers  of 
persons  through  the  infection  of  milk. 

Each  year,  as  education  progresses  and  the  legal  requirements 
are  more  strictly  enforced,  the  proportion  of  unre])orted  cases  grows 
less.  However,  a  study  of  returns  made  to  the  State  Department 
of  Health  shows  clearly  that  a  large  number  of  cases  especially 
of  the  so-called  "  minor "  communicable  diseases  —  such  as 
measles,  German  measles,  chickenpox  and  whooping  cough  —  are 
still  not  reported.  Failure  to  comply  with  the  requirements  of 
the  law  are  variously  accounted  for;  most  frequently  by  careless- 
ness on  the  part  of  physicians  and  failure  to  arrive  at  a  diagnosis 
or  ignorance  on  the  part  of  heads  of  households  of  the  require- 
ment in  regard  to  reporting  when  no  physician  is  in  attendance. 
It  is  a  duty  of  a  local  health  officer  to  see  that  every  person  in 
his  community  upon  whom  the  law  places  a  responsibility  is  given 
reasonable  opportunity  to  become  familiar  with  the  law  and  then 
to  prosecute  persistent  or  wilful  violators  when  adequate  legal 
evidence  is  at  hand. 

Inability  to  arrive  at  a  diagnosis  may  occasionally  constitute  a 
reasonable  excuse  for  failure  on  the  part  of  a  physician  to  rejDort 
a  case  of  communicable  disease.  This  excuse  will  appear  less 
frequently  w'lien  it  is  generally  understood  that  in  at  least  numy 
instances  the  plea  of  inability  to  make  a  diagnosis  of  a  eom- 
nmnicable  disease  reflects  upon  the  initiative  and  skill  of  the 
physician.  The  Sanitary  Code  requires  physicians  to  make  cul- 
tures and  submit  them  for  examination  in  all  cases  in  which  there 
is  reason  to  suspect  the  existence  of  diphtheria,  and  to  submit 
blood  specimens  for  the  Wassermann  test  in  cases  suspected  of  hav- 
ing syphilis  and  for  agglutination  tests  Avhenever  there  is  reason 
to  suspect  the  existence  of  typhoid  or  paratyphoid  fever.  Unless 
a  physician  has  resorted  to  these  or  other  appropriate  and  readily 
available  laboratory  aids,  failure  to  arrive  at  a  diagnosis  within  a 
reasonable  length  of  time  should  not  be  regarded  as  an  acceptable 
excuse. 


Public  Health  ^N'tjrsing  99 

While  it  is  the  duty  of  a  public  health  nurse  to  bring  to  the  atten- 
tion of  the  local  health  officer  any  case  in  which  she  suspects  the 
existence  of  a  communicable  disease,  it  is  also  a  fact  that  busy 
health  officers  are  at  times  unnecessarily  annoyed  by  being  called 
upon  to  visit  cases  when  such  suspicions  are  not  well  founded, 
This  is  particularly  true  in  rural  conununities  in  which  health 
officers  are  busy  practitioners  and  where  a  visit  to  a  suspected 
case  may  involve  traveling  a  considerable  distance.  Unless  the 
nurse  is  skilled  in  the  detection  of  communicable  disease  or  is 
acting  under  local  instnictions,  she  should  endeavor  to  have  her 
suspicions  promptly  confirmed  by  a  physician  —  whether  by  the 
family,  school,  or  other  physician  depending  upon  circumstances. 
Pending  the  result  of  his  investigation,  she  should  keep'  the  case 
under  observation  and  endeavor  to  see  that)  necessai-y  precautions 
are  taken. 

Information  Regarding  Communicable  Diseases 
It  is  impossible,  in  a  work  of  this  kind,  to  enter  into  a  detailed 
discussion  of  all  the  common  and  important  communicable 
diseases.  The  Division  of  Communicable  Diseases  has  prepared 
for  distribution  a  series  of  circulars  containing  essential  informa- 
tion regarding  the  various  common  communicable  diseases.  It 
has  also  prepared  for  the  use  of  health  officers  a  manual, 
"The  Prevention  and  Control  of  Communicable  Diseases,"  in 
which  are  outlined  the  essential  points  in  the  epidemiology  of  the 
various  diseases.  A  pamphlet  entitled  "Cooperation  in  the  Control 
of  Communicable  Diseases  among  School  Children"  deals  par- 
ticularly with  the  prevention  and  control  of  school  outbreaks, 
and  contains  the  special  rules  and  regulations  of  the  State  Depart- 
ments of  Health  and  Education  for  exclusion  from  school  of 
children  suffering  from  communicable  diseases  or  in  whose  homes 
cases  occur.  Two  circulars,  "  The  Conduct  of  an  Isolation  Period 
for  Communicable  Disease  in  a  Home  "  and  "  Regulations  and 
Instructions  for  Cleansing  and  Disinfection,"  give  detailed 
advice  regarding  procedure  and  precautions  in  caring  for  cases 
in  the  home.  The  "  Public  Health  Manual  "  contains  the  State 
Sanitary   Code  together  with  important  sections  of  the  Public 


100  State  Departmei^tt  of  Health 

Health,   Education,   Penal   and   other  laws,   portions    of  which 
relate  to  the  control  of  communicable  diseases. 

One  who  has  carefully  studied  these  various  publications  will 
have  acquired  a  fairly  adequate  working  knowledge  of  the  pre- 
vention and  control  of  communicable  diseases.  All  of  them  will 
be  sent  to  any  public  health  nurse  upon  request.  It  is  suggested 
that  they  be  secured  and  maintained  as  a  "working  library," 
to  be  used  in  conjunction  with  this  manual. 

Upon  request,  the  name  of  a  public  health  nurse  will  be  placed 
upon  the  mailing  list  for  Health  News  and  The  Public 
Health  Nukses"  BuLLETrisr  which  axe  published  monthly  and 
iar  the  various  bulletins  issued  by  the  Department.  These  con- 
tain articles  covering  current  information  in  regard  to  com- 
municable diseases,  as  well  as  other  material  of  interest  to  health 
workers.  The  bulletins  constitute  an  official  medium  of  com- 
munication with  health  officers  and  nurses  through  which  they  are 
apprised  of  amendments  or  additions  to  the  Sanitary  Code  or 
laws  relating  to  health  administration.  These  can  be  conveniently 
bound  by  use  of  "  ring  binders  "  which  can  be  purchased  at  any 
stationery  store  at  small  cost. 

Syphilis  and  Gonoeehe.! 
Syphilis  and  gonorrhea  should  be  considered  among  diseases 
common  to  adult  life.  Since  their  etiology  has  been  established 
it  has  become  possible  to  estimate  their  prevalence  in  a  comnmnity 
by  a  careful  study  of  its  social  life.  Certain  social  conditions  have 
been  proven  to  definitely  increase  their  prevalence  and  during  the 
recent  war  advantage  was  taken  of  this  knowledge  to  produce  con- 
ditions that  would  tend  to  prevent  their  spread.  The  results 
attained  were  veiy  promising  and  justified  a  continuation  of  the 
campaign  on  a  wider  scale.  The  program  adopted  to  produce 
these  favorable  conditions  is  three  fold :  First,  a  vigorous  educa- 
tional campaign  is  necessary;  for  all  classes  of  society  are  alike 
ignorant  of  the  true  nature  of  these  diseases,  their  communi- 
cability  or  the  possibility  of  their  cure;  second,  facilities  for 
diagnosing  and  treating  the  diseases  must  be  made  available. 
Owing  to  a  reluctance  on  the  part  of  the  public  in  the  past  to 
acknowledge  or  speak  of  diseases  of  the  generative  organs  and  the 


Public  Health  Xuiii:.i;N"(^^    :  ]€,]• 

cooperation  of  the  physicians  in  this  evasion,  their  intelligent 
and  successful  treatment  was  possible  at  only  a  very  few 
dispensaries  and  specialists'  offices;  third,  social  conditions  must 
be  developed  that  will  eliminate  the  foci  of  infection  and  limit 
the  activities  of  the  carriers. 

The  principal  agents  upon  whom  the  burden  of  this  new  pro- 
gram rests  are  the  public  health  officials,  and  of  these  the  public 
health  nurse  has  unusual  opportunities.  Her  duties  will  not  only 
bring  her  in  touch  with  all  those  who  come  to  the  dispensaries  but 
in  her  follow-up  work  she  will  come  in  contact  with  other  members 
of  the  family  and  community,  and  this  may  prove  to  be  her 
largest  field. 

It  is  highly  important,  therefore,  that  she  be  adequately  quali- 
fied to  do  social  work.  Patients  coming  to  the  venereal  disease 
clinic  are  usually  not  very  ill,  frequently  they  are  not  uncom- 
fortably incapacitated  and  therefore  they  do  not  hesitate  to  dis- 
continue treatment  if  the  least  inconvenience  is  encountered,  unless 
they  have  been  carefully  impressed  with  the  seriousness  of  their 
condition.  Proper  advice  and  instruction  should  be  given  the 
patient  by  the  physician  on  the  occasion  of  the  first  visit,  but  in 
many  cases  it  will  be  necessary  for  the  nurse  to  continue  this 
education  in  order  to  keep  the  patient  under  treatment. 

It  is  not  an  unusual  experience  for  a  nurse  to  have  several  mem- 
bers of  a  family,  in  some  instances  both  parents  and  children, 
visit  the  clinic  for  examination  after  one  of  her  visits  to  the  home 
of  a  patient.  Some  patients,  by  changing  their  residence,  lose 
contact  with  the  clinic  unless  the  nurse  keeps  in  touch  with  them. 

Three  classes  of  persons  with  whom  the  nurse  will  work  are  the 
uncured,  the  untreated  and  the  undiagnosed.  Her  first  work  is 
with  the  uncured  patient  who  starts  treatment  at  the  dispensary. 
Her  specific  qualifications  in  such  cases  are  tact  and  sympathy. 
These  patients  are  usually  unduly  self-conscious  of  their  condition 
and  often  feel  that  they  are  despised  because  of  their  infection. 
If  they  are  convinced  that  a  cure  is  possible  and  that  th.ose  con- 
nected with  the  dispensary  are  seriously  interested  in  treating 
them,  their  enthusiastic  cooperation  is  the  rule. 

While  working  among  the  uncured  patients  the  nurse  will  find 
persons  who  need  treatment  but  are  not  receiving  it.     Among 


'X'0*2  ,  &TAT3  .Department  of  Health 

these  will  be  foimd  some  who  started  treatment  with  a  private 
physician  and  stopped  before  they  were  cured,  some  who  are 
ignorant  of  the  necessity  for  treatment  or  do  not  know  where  to  go 
to  be  treated,  and  some  wdio  realize  that  they  are  ill  but  do  not 
recog-nize  the  disease.  All  of  these  should  receive  the  nurse's 
immediate  attention.  If  those  persons  who  are  aware  of  the 
nature  of  their  infection  are  told  of  the  clinic  and  encouraged  to 
visit  it,  they  usually  do  so,  but  those  who  are  ignorant  of  the 
true  cause  of  their  illness  are  frequently  less  tractable.  It  may 
be  that  these  patients  have  made  their  own  diagnoses,  or  it  may  be 
that  a  physician  was  consulted  years  ago  and  the  patient  assumes 
that  the  present  trouble  is  a  continuation  of  the  previous  sickness. 
Such  cases  should  be  persuaded  to  visit  their  family  physician, 
if  they  have  one,  or  to  go  to  the  dispensary  where  the  proper 
specimens  can  be  taken.  The  nurse  should  qualify  herself  so  as 
to  be  able  to  take  specimens  from  women  where  gonorrhea  is  sus- 
pected. Sometimes  it  is  more  desirable  to  have  the  first  laboratory 
specimens  for  the  diagnosis  of  gonorrhea  taken  from  women  or 
children  in  their  homes  and  not  to  have  them  visit  the  clinic  until 
treatment  is  begun. 

Finally  there  are  those  persons  but  recently  infected  in  whom 
the  disease  has  not  been  diagnosed.  There  are  two  groups  of 
these  w^hich  w^e  should  consider.  First,  those  cases  that  have  nor, 
been  discovered,  and  where  the  patients  may  or  may  not  know  they 
are  ill.  It  may  be  a  primary  sore  that  attracts  the  attention  of 
the  nurse  or  a  secondaiy  rash  and  indisposition  may  cause  the 
patient  to  speak  of  himself.  There  are  many  signs  and  symptoms 
that  should  arouse  the  nurse's  suspicion,  but  it  must  be  remem- 
bered that  the  diagnosis  should  always  be  made  by  a  physiciim 
and  that  he  should  always  confirm  his  clinical  diagnosis  by  having 
a  laboratoiy  examination  of  the  proper  s]>ecimens.  The  nurse 
should,  however,  invariably  report  all  such  suspicious  cases  with 
her  reason  for  so  doing  either  to  the  family  physician  or  to  the 
physician  at  the  clinic  and  be  advised  by  his  judgment  with 
regard  to  further  action.  The  second  group  includes  those  per- 
sons, who  have  been  unconsciously  exposed  to  either  of  the 
diseases.  It  is  among  this  group  that  the  nurse  will  be  called  upon 
to  do  her  most  tactful  educating.     If  a  father  has  just  recently 


Public  Health  jS^uusing  103 

contracted  gonorrhea  or  has  a  recurrence  of  his  earlier  infection, 
the  greatest  care  must  be  taken  to  keep  the  infection  from  spread- 
ing to  other  members  of  the  family.  A  member  of  a  family  who 
has  contracted  syphilis  and  who  has  taken  precautions  while  the 
primary  sore  existed  may  not  realize  the  sore  mouth  he  now  has 
is  another  stage  of  the  same  disease.  One  can  readily  see  how 
entire  families  may  be  infected  iimocently  from  one  of  their 
numlier  having  undiagnosed  mucous  patches  in  the  mouth.  These 
conditioais  must  be  borne  in  mind  by  the  nurse  when  she  visits 
the  jiome  of  a  patient  who  is  attending  a  clinic. 

Another  contact  that  is  urgently  in  need  of  the  advice  of  the 
nurse  is  the  pregnant  mother.  The  nurse  should  see  that  she 
is  examined  very  carefully  by  a  physician,  for  if  infected  and 
treatment  is  instituted  early  enough,  a  well  infant  may  be  born. 
When  we  consider  the  great  number  of  stillbirths  and  deaths  of 
infants  under  one  year  of  age  due  to  syphilis  alone,  we  can  under- 
stand the  importance  of  this  investigation.  Persons  with  either 
acute  or  discharging  lesions  of  gonorrhea  or  syphilis  must  not 
be  permitted  to  care  for  children  if  it  can  be  avoided.  If  there 
is  no  alternative  then  they  must  be  most  carefully  instructed  in 
how  to  avoid  infecting  their  charges. 

The  public  health  nurse  should  cooperate  with  other  specializing 
nurses  of  her  district.  If  there  is  a  regularly  appointed  venereal 
disease  nurse  she  should  be  informed  by  the  public  health  nurse 
of  her  investigations  and  discoveries.  If  there  is  no  venereal 
disease  nurse  in  the  district,  then  the  public  health  nurse  should 
learn  from  these  specializing  nurses  who  work  in  her  district  the 
discoveries  which  they  malvc  and  the  suspicions  they  have  of  the 
presence  of  either  syphilis  or  gonorrhea  and  should  assist  in 
investigating  them.  Instances  are  recorded  where  destnictive 
pharyngitis  or  suppurating  glands  were  treated  for  years  as 
tuberculosis,  until  a  more  careful  search  of  the  contact  condi- 
tions proved  them  to  be  of  syphilitic  origin. 

This  in  a  brief  way  outlines  some  of  the  opportunities  of  a 
public  health  nurse  in  the  therapeutic  control  of  venereal  diseases ; 
but  she  has  another  large  field  in  the  social  welfare  of  the  com- 
munity. 

Every  community  has  a  number  of  social  agencies  that  are 
interested  in  the  control  of  communicable  diseases.   Many  of  these 


104  State  Depaktment  of  Health 

are  anxious  to  assist  in  preventing  the  spread  of  venereal  diseases 
but  they  are  not  working  at  maximum  eflSeiency  because  they  are 
not  cooperating  in  a  common  program.  Usually  these  committees 
as  for  example  tuberculosis  and  child  welfare  committees,  Kave 
been  organized  for  some  special  work  and  as  that  progresses  tJiey 
have  gi'adually  taken  up  other  activities  or  would  Avillingly  assist 
in  other  communitj^  service  if  they  were  properly  directed.  The 
nurse  should  devise  a  plan  to  bring  together  social  agencies  and 
the  law  enforcement  authorities.  The  cooperation  of  police 
magistrates,  probation  officers  and  those  in  charge  of  wayward 
girls  should  be  secured  in  carrying  out  a  general  scheme  instead 
of  impersonally  administering  the  law. 

Civilian  committees  should  be  stimulated  to  provide  machinery 
which  will  tend  to  restore  these  unfortunates  to  that  station  of 
society  from  which  they  came  before  they  fell  into  the  hands  of 
the  law.  This  is  a  very  large  field  and  one  in  which  much  work 
remains  to  be  done.  ISlo  person  is  so  well  equipped  as  the  nnrse 
to  restore  confidence,  both  in  the  patient  herself  and  in  those  who 
should  be  interested  in  her.  She  can  at  the  proper  time  report 
the  freedom  of  the  patient  from  infection  and  assist  in  selecting 
her  emplo}Tnent.  This  interest  shown  by  the  nurse  will  be  most 
helpful  in  restoring  self-respect  to  the  patient.  The  defective  girl 
will  be  discovered  by  her  and  proper  care  secured  so  as  to  prevent 
her  continuing  the  life  from  which  she  was  rescued ;  if  institu- 
tional care  is  indicated  it  should  be  secured.  If  the  nurse  can 
demonstrate  to  a  community  its  share  in  the  responsibility  for  the 
care  of  such  patients  ^e  will  have  accomplished  much  for  the 
future  health  of  the  people. 

Relief  committees  and  organizations  such  as  settlements  and  the 
Salvation  Army  posts  should  be  interested  in  securing  treatment 
for  the  infected  which  they  encounter.  They  are  always  very  glad 
to  cooperate  with  the  nurse  but  they  must  be  interviewed  and  a 
definite  plan  outlined.  Local  commercial  and  industrial  associa- 
tions must  be  interested.  It  will  be  found  that  many  of  these 
organizations  have  already  started  work  according  to  their  own 
plans  and  it  will  only  be  necessary  to  coordinate  this  with  the 
community  work. 

A  fourth  activity  is  to  provide  adequate  recreational  opportuni- 
ties for  the  young  people  and  to  secure  proper  supervision  over 


Public  Health  Nursing  105 

those  which  are  already  functioning.  This  is  a  most  important 
piece  of  work  aiul  great  care  must  be  exercised  in  choosing  the 
committee  wliich  will  have  it  in  hand.  They  must  be  possessed 
of  sound  judgment  and  must  be  appreciative  of  the  demands 
of  the  young  people.  Experience  has  sho\\'n  that  a  suffi- 
cient variety  of  well  organized  places  of  amusements  where  the 
young  people  can  feel  free  to  do  what  they  wish,  provided  there 
is  order  and  decency,  will  do  more  toward  controlling  the  spread 
of  venereal  infection  than  many  laws. 

The  public  health  nurse  may  find  when  she  starts  work  that, 
unless  she  has  been  specially  trained,  the  social  service  phase  of 
her  activities  will  be  exceedingly  difficult.  Even  if  she  has  been 
trained  in  social  service  methods  in  one  of  the  larger  cities,  these 
will  have  to  be  gTeatly  modified  to  be  of  value  in  the  rural  dis- 
tricts. This  must  not  discourage  her.  She  must  make  the  start, 
relying  on  her  tact  and  common  sense  to  guide  her.  One  great 
temptation  which  she  must  early  learn  to  avoid  is  the  devotion 
of  too  much  time  to  the  individual  case.  Her  work  is  commun- 
ity work  and  preventive  in  character  rather  than  therapeutic. 
Therefore  when  she  seesi  an  infected  person  her  first  reaction 
should  be  to  protect  the  well  and  to  limit  the  contacts.  She  will 
be  called  upon  to  give  advice  more  often  in  venereal  disease  work 
than  in  any  other  but  she  must  remember  to  speak  advisedly  and 
always  to  refer  these  people  to  the  physician  for  diagnosis  and 
specific  advice.  Her  position  as  an  educator  is  an  important  one 
and  she  should  always  try  to  find  time  to  "  talk  it  out "  with  a 
mother  or  girl  who  is  puzzled  over  some  sex  problem.  Mothers 
will  want  her  to  help  them  to  instruct  their  children  and  the 
nurse  should  be  prepared  to  offer  helpful  suggestions;  especially 
should  she  teach  the  mother  the  correct  names  of  the  generative 
organs.  Much  of  the  reluctance  of  the  average  person  to  talk 
of  sex  matters,  is  removed  when  his  or  her  vocabulary  is  enlarged 
to  contain  these  correct  terms. 

In  a  word,  the  public  health  nurse's  work  will  be  medical, 
social  and  educational.  Some  clients  will  require  all  three,  others 
but  one  or  two,  and  the  nurse  will  be  obliged  to  determine  which 
they  need  from  her  observation  at  the  time  of  the  visit.  Which- 
ever is  indicated  should  be  given,  for  all  are  equally  important  and 
valuable  to  the  community. 


106  State  Department  of  Health 


CHAPTER  VIII 
Public  Health  Nursing  and  Tuberculosis 

Tuberculosis,  a  communicable  disease,  is  preventable  and  cur- 
able. Because  of  its  great  frequency,  wide  distribution  and  the 
vast  amount  of  suffering  whicb  it  causes,  it  is  the  most  important 
disease  with  which  public  health  workers  are  concerned.  The 
many  and  complex  underlying  sanitary,  economic,  social  and 
industrial  factors  responsible  for  its  prevalence,  make  its  practi- 
cal control  exceedingly  difficult. 

There  are  numerous  and  varied  agencies  concerned  directly  or 
indirectly  in  the  fight  against  tuberculosis.  Of  these  the  tuber- 
culosis hospital  is  undoubtedly  the  most  important  single  agency; 
the  tuberculosis  visiting  nurse  ranks  next.  In  this  chapter  are 
described  the  duties  of  and  procedures  to  be  followed  by  nurses 
engaged  in  tuberculosis  work. 

For  details  regarding  the  nature  of  the  disease,  its  causes, 
sjanptoms  and  treatment,  the  reader  is  referred  to  the  pamphlet 
entitled,  "  What  You  Should  Know  About  Tuberculosis." 

Tuberculosis  may  attack  any  individual,  regardless  of  age,  sex, 
race,  or  social  status.  It  is,  however,  becoming  a  class  disease,  i.  e., 
"a  disease  of  the  masses."  In  this  country  it  kills  annually 
between  150,000  and  160,000  (about  9  per  cent  of  all  deaths), 
and  of  this  number  the  pulmonary  form  causes  over  SO  per  cent. 
About  one-half  of  these  deaths  occur  in  individuals  between  20 
and  40  years  of  age.  It  has  been  estimated  that  out  of  the 
present  population  of  100,000,000  in  this  countiy  about  9,000,- 
000  will  succumb  to  this  disease  unless  the  proper  measures  are 
carried  out. 

From  the  results  obtained  at  Framingham,  Mass.,  it  would 
appear  that  for  every  death  from  tuberculosis,  there  are  at  a  given 
time  about  eight  active  cases  of  the  disease,  of  which  between  six 
and  seven  are  pulmonary  tuberculosis. 

Tubei'culosis  of  the  lungs  is  the  type  of  the  disease  with  which 
the  public  health  nurse  will  be  most  concerned ;  therefore  what 
follows  relates  mainly  to  pulmonary  tuberculosis. 

The  following  classification  is  the  one  ordinarily  used  to  desig- 
nate the  severnl  stages  of  the  disease: 


Public  Health  jSTuksing  107 

Incipient  (beginning) :  There  is  very  slight  affection  of 
one  or  both  lungs.  There  are  no  severe  symptoms,  such  as 
high  fever,  rapid  pulse,  dyspnea,  great  weakness,  large  hem- 
orrhages, or  severe  cough  and  much  expectoration.  Tubercle 
bacilli  may  be  present  or  absent.  'No  other  part  of  the  body  is 
tuberculous  and  there  is  no  other  illness.  Under  proper  treat- 
ment 3  out  of  4  patients  in  this  "early"  or  "curable"  stage 
apparently  recover. 

Moderately  advanced:  There  is  a  larger  area  of  involvement, 
but  not  much  lung  tissue  has  been  destroyed  and  while  the 
patient  has,  as  a  rule,  more  marked  symptoms  of  the  disease  he 
has  no  serious  complications  and  is  not  usually  physically  inca- 
pacitated. About  1  out  of  5  moderately  advanced  patients  appar- 
ently recover  under  proper  treatment. 

Far  advanced:  The  patient  has  a  large  area  of  lung  affected, 
and  his  lung  tissue  is  being  destroyed.  His  symptoms  are  marked 
and  severe;  he  often  has  serious  complications  and  is  practically 
incapacitated.  Only  1  out  of  about  150  to  200  patients  in  this 
stage  apparently  recover. 

After  treatment,  one  of  the  following  conditions  will  be  found : 

Unimproved:  Condition  is  the  same  as  when  treatment  was 
begun  or  else  the  disease  has  advanced,  when  it  is  called  a  pro- 
gressive case. 

Improved:  The  patient's  symptoms  have  improved,  but  he  may 
still  cough  and  expectorate  tubercle  bacilli. 

Quiescent:  The  disease  in  the  lungs  is  stationary  or  improving 
and  while  the  patient  may  or  may  not  cough  and  expectorate 
tubercle  bacilli  his  other  symptoms  are  practically  absent  and  this 
condition  has  continued  for  at  least  two  months. 

Apparently  arrested:  The  diseased  lung  tissue  has  become 
healed  and  all  general  symptoms  and  expectoration  of  bacilli  have 
been  absent  for  three  months.  When  this  condition  persists  for 
six  months,  the  case  is  considered  arrested.  When  an  "  arrested" 
case  remains  so  for  two  years  under  ordinary  conditions  of  life 
it  is  apparently  cured.  As  long  as  the  patient  is  discharging 
tubercle  bacilli  he  is  an  infectious,  and  an  open  case.  When  this 
giving  off  of  germs  has  not  yet  begun  or  else  has  ceased,  the  case 
is  noninfectious  or  closed.     It  is  obvious  that  only  the  open  cases 


108  State  Department  of  Health 

will  transmit  the  disease  to  others  when  proper  precautions  are 
not  taken.  In  very  many  of  the  really  incipient  cases  tubercle 
bacilli  are  not  found  in  the  sputum  as  ordinarily  examined; 
occasionally  a  far  advanced  patient  may  not  expectorate  bacilli. 
However,  a  noninfectious  patient  may  at  any  time  become  infec- 
tious, which  fact  is  of  the  utmost  importance  in  connection  with 
the  prevention  of  the  spread  of  the  disease  to  others. 

Measures  foe,  Prevention'  and  Control 

The  measures  to  be  taken  to  control  tuberculosis,  to  prevent 
its  spread,  and  to  lessen  its  incidence  with  the  hope  of  ultimately 
eradicating  it,  must  be  aimed  first  at  preventing  infection. 
When  this  has  occurred  active  disease  should  not  be  allowed  to 
develop ;  if  it  does  the  patient  should  be  cared  for  in  such  manner 
that  not  only  will  he  be  prevented  from  transmitting  it  to  others 
but  will  himself  if  possible  become  arrested  or  apparently  cured. 
Finally,  after  arrest  has  taken  place,  recurrence  or  reinfection 
must  be  guarded  against. 

Practically,  these  aims  require  an  enoi-mous  nimiber  of  agencies 
all  working  at  maximum  efficiency  and  ia  harmonious  coopera- 
tion. The  necessary  measures  have  been  determined  and  when- 
ever and  wherever  they  have  been  properly  carried  out  excellent 
results  have  followed.* 

To  prevent  infection  necessitates  that  the  tubercle  bacillus  be 
located  and  destroyed  at  its  source.  Since  this  is  not  always  pos- 
sible, every  individual  should  be  taught  to  take  the  proper  pre- 
cautions in  coughing,  sneezing,  spitting,  or  otherwise  contammat- 
ing  persons  or  objects  with  his  discharges. 

Every  case  of  tuberculosis  should  be  located  at  the  earliest  pos- 
sible moment;  it  is  essential  that  early  diagnosis  be  secured.  For 
this  purpose  all  physicians  should  be  educated  in  present  day 
methods,  and  clinics  and  dispensaries  where  specially  qualified 
men  can  be  consulted  should  be  available.  All  persons  suspected 
of  having  tuberculosis  should  be  repeatedly  examined  until  a 
definite  diagnosis  is  made.     This  applies  also  to  those  who  have 


*  Their  employment  bonefitg  not  only  the  tuberculosis  situation  but  also, 
directly  or  indirectly,  assists  in  the  solution  of  many  other  public  health  and 
welfare  problems. 


Public  Health  Nursing  109 

come  into  more  or  less  intimate  and  prolonged  contact  with  tuber- 
culous patients  in  tlie  home,  factory,  mill,  school,  etc.  As  an  aid 
in  diagnosis,  free  labara;tory  examinations  of  sputum  and  other 
suspected  discharges  should  he  made  by  local  ox  state  laboratories- 
It  should  be  emphasized  that,  whenever  possible,  a  diagnosis 
should  be  made  without  waiting  for  a  positive  laboratory  finding. 

All  cases  of  tuberculosis  must  be  reported  by  physicians  to 
the  health  authorities,  who  must  record  them  and  maintain  con- 
stant direct  or  indirect  supervision  over  them  until  they  are  appar- 
ently cured  or  have  died.  In  the  event  of  a  patient  leaving  the 
jurisdiction  of  one  health  officer  to  go  into  that  of  another,  this 
fact  must  be  reported  to  the  latter  so  that  he  may  begin  super- 
vision at  once. 

All  reports  of  suspected  cases  made  in  writing  by  any  respon- 
sible individual  (which  reporting  is  authorized  and  should  be 
encouraged)  must  be  investigated  by  the  local  health  officer;  he 
is  required  to  make  every  effort  to  determine  whether  or  not  the 
case  is  tuberculosis.  In  the  meanwhile  the  precautions  required 
of  positive  tuberculosis  cases  should  be  applied  to  suspects. 

Isolation  or  segregation  of  all  patients  with  tubercle  bacilli 
in  their  sputum,  and  especially  the  advanced  and  helpless  case, 
is  obviouslj  essential.  Such  isolation  is  best  secured  at  a  tuber- 
culosis sanatoxium  or  hospital ;  if  this  is  iM)t  practicable  isolation 
should  be  required  at  home.  In  the  latter  case,  the  following 
procedures  and  precautions,  prescribed  by  the  Kew  York  State 
Commissioner  of  Health,  must  be  carried  out  under  the  super- 
vision of  the  attending  physician,  health  officer  or  nurse : 


PROCEDURES  AND  PRECAUTIONS  TO  BE  TAKEN  ON  THE  PREMISES 
OCCUPIED  BY  A  PATIENT   HAVING  TUBERCULOSIS 

Care  of  sputum 
The  patient  sliould  spit  into  a  paper  sputiim  cup;  burn  this  cup  and  its 
contents  daily  or  oftener;  hold  a  handkerchief  or  cloth  before  the  mouth 
Avhen  coughinp:  or  s^neezing;  use  paper  napkins  or  gauze  handkerchiefs,  which 
can  be  burned  daily;  should  not  swallow  sputum;  avoid  soiling  hands  -with 
sputum — (if  this  occurs  the  hands  should  be  thoroughly  cleaned  with  hot 
water  and  soap)  ;  thoroughly  wash  with  hot  water  and  soap  any  article 
aecidently  soiled  with  sputimT,  shooild  not  kiBs  anyone  (it  is  eBpecially 
dangerous  for  the  patient  to  kiss  children) ;  should  not  handle  raw  food 
imless  the  hands  have  been  thoroughly  washed  with  hot  water  and  soap. 


110  State  Depaetment  of  Health 

Care  of  premises,  eating  utensils  and  linen 
Dry  sweeping  and  dusting  should  be  avoided;  dust  from  any  source  should 
be  prevented,  if  possible;  patient  should,  if  possible,  be  provided  with  a 
separate  bed  and  room,  preferably  a  room  which  admits  much  air  and  light, 
especially  sunlight;  patient  should  have  separate  dishes,  linen  and  handker- 
chiefs and  other  articles  for  personal  use,  and  these  should  be  washed  and 
cleaned  separately. 

Other  precautions 
Patient  should  not  associate  freely  with   children  and  should  with  very 
special  care  observe   all   precautions   in  their   presence;    all   members  of   the 
patient's  family  and  other  household  associates  should  be  carefully  examined 
for  tuberculosis. 

All  apartments  or  premises  vacated  by  the  death  or  removal  of 
a  tuberculous  patient  must  be  cleansed,  renovated  or  disinfected 
as  the  case  may  require. 

A  tuberculous  individual  should  not  prepare  or  in  any  way 
handle  food  intended  for  others  which  will  not  be  cleansed  or 
cooked  before  consumption ;  he  should  therefore  not  engage  in 
such  occupation  as  cook,  baker,  butcher,  milk  dealer,  etc.  Dusty 
trades,  because  of  the  irritant  effects  of  the  dust,  should  be  avoided. 
To  prevent  infection  from  tuberculous  cows,  milk  and  its  fresh 
products  should  not  be  used  unless  pasteurized  except  in  cases 
where  the  cows  have  been  tuberculin  tested  and  shown  to  be  free 
from  tuberculosis. 

In  order  that  the  individual  may  himself  prevent  taking  in  the 
germs  of  tuberculosis  he  should  avoid  prolonged  and  intimate  asso- 
ciation with  persons  known  to  have  tubercle  bacilli  in  their 
sputum,  especially  if  the  latter  do  not  strictly  carry  out  the  pre- 
cautions prescribed.  Sleeping  in  the  same  bed,  or  working  in  the 
same  room  with  a  tubei^culosis  patient,  if  such  workroom  is  small 
and  not  well  aired  and  sunned,  is  especially  dangerous.  He 
should  not  use  common  drinking  cups,  or  should  he  put  fingers  or 
other  objects  which  do  not  belong  there  into  the  mouth.  He 
should  never  handle  food  with  unwashed  hands.  Dusty  atmos- 
pheres and  dark,  damp,  ill  ventilated  rooms,  whether  in  the  home 
or  elsewhere,  should  be  avoided  by  him.  Decayed  teeth  should 
receive  proper  attention  as  well  as  any  defects  of  the  nose  or  chest 
interfering  with  proper  breathing.  Children  require  special  pro- 
tection because  they  are  more  apt  to  become  infected  than  adults. 

If  infection  has  occurred  and,  unfortunately  this  is  probably 
the  case  in  a  large  part  of  our  present  population,  it  is  essential 


Public  Health  Nursing  111 

that  the  individual  resistance  both  general  and  local  be  main- 
tained at  as  high  a  level  as  possiljle.  The  public  as  a  whole  should 
see  to  it  that  conditions  in  the  home,  factory,  mill,  school,  etc.,  be 
so  improved  that  there  is  no  overcrowding,  and  that  there  is  sup- 
plied to  everyone  an  abundance  of  fresh  air  and  sunshine.  Eco- 
nomic and  social  defects  should  be  corrected  as  far  as  possible. 
Better  wages  and  lower  cost  of  living  tend  to  reduce  poverty 
and  want  and  sufficient  holidays  and  vacations,  parks,  play- 
grounds, allow  for  the  necessary  amount  of  recreation.  The 
individual  should  avoid  intemperance  or  excess  in  work  or  play 
and  dissipation  of  any  kind.  The  diet  should  be  generous  and 
include  fat  food  which  tends  to  increase  the  resistance  against 
infection ;  rest,  fresh  air  and  sunshine  are  essential,  as  is  also 
the  avoidance  of  the  diseases  and  conditions  mentioned  above  as 
predisposing  to  the  development  of  the  disease.  Children  from 
tuberculous  families,  those  who  are  anemic  and  the  so-called  pre- 
tubereulous,  should  be  cared  for  in  preventoria  or  in  "  open 
air  "  schools,  where  the  physical  care  of  the  child  takes  precedence 
over  its  education.  Preventorium  treatment  for  "  run  down " 
adults  is  also  most  desirable. 

When  the  disease  has  developed,  every  effort  should  be  made  to 
obtain  its  arrest.  For  this  purpose  treatment  at  a  sanatorium  or 
hospital  is  by  far  the  most  desirable ;  that  at  a  camp  or  at  home 
under  the  supervision  of  a  dispensary  or  class  ranks  in  value  in 
the  order  given. 

When  the  disease  has  been  arrested  every  effort  should  be  made 
to  avoid  a  recurrence  or  a  reinfection. 

The  general  public,  including  the  tuberculous  individual,  re- 
quires enlightenment  as  to  the  tuberculosis  problem  so  that  the 
necessary  statutes  may  be  enacted  and  properly  enforced,  and 
institutions  and  other  agencies,  public  and  private,  established  and 
maintained.  The  public  should  be  made  to  understand  thoroughly 
that  the  tuberculous  patient  should  not  be  shunned,  but  so  aided 
that  he  will  not  only  not  be  a  menace  to  the  community  but  also 
be  restored  to  useful  citizenship. 


112  State  Department  of  Health 


The  Tuberculosis  Xue^e 

In  'New  York  State,  nurses  engaged  in  tuberculosis  work  are 
employed  in  one  of  several  ways.  In  counties  where  the  estab- 
lishment of  a  tuberculosis  hospital  is  mandatory,  the  board  of 
managers  of  such  hospital  is  required  and  in  other  counties  the 
board  of  supervisors  is  authorized  to  "  employ  a  county  nurse,  or 
an  additional  nurse  or  nurses,  if  it  deems  necessary,  for  the  dis- 
covery of  tuberculosis  cases  and  for  the  visitation  of  such  cases  and 
of  patients,  discharged  from  the  hospital  and  for  such  other  duties 
as  may  seem  appropriate."  Under  the  authority  of  the  public 
health  law,  the  board  of  health  of  any  municipality  may  appoint 
such  nurse  or  nurses.  Local  tuberculosis  organizations,  county  or 
city,  employ  visiting  nurses  either  alone  or  in  conjunction  with 
some  public  agency.  Depending  upon  how  these  nurses  are 
employed,  their  fields  of  activity  will  necessarily  vary  as  will  the 
scope  of  their  duties,  though  to  a  minor  extent.  For  instance,  a 
nurse  employed  by  the  local  health  authorities  acts  as  the  repre- 
sentative of  the  health  officer  and  as  such  has  certain  official  duties 
and  responsibilities  which  the  private  nurse  does  not  have.  Or  a 
nurse  attached  to  a  dispensary  acts  as  the  physician's  assistant, 
taking  temperature,  pulse,  respiration  and  weight,  recording 
same,  preparing  patients  for  examination  and  amplifying  the 
physician's  instructions.  In  the  main,  however,  their  activities 
are  practically  identical;  what  follows  is  generally  applicable. 

Depending  upon  the  size  of  the  locality,  and  the  amount  of 
tuberculosis  work  already  done,  the  nurse  may  have  such  functions 
to  perform  as  will  arouse  sentiment  in  the  community  for  devel- 
opment of  tuberculosis  work  or  more  active  prosecution  of  that 
already  begun.  It  is  advisable  for  the  nurse  on  entering  her  field 
to  make  a  survey  or  study  of  all  conditions  and  factors  relating  to 
tuberculosis  in  the  community.  This  should  include  a  tabulation 
of  the  actual  number  of  reported  cases  and  deaths,  and  the  numeri- 
cal ratio  Ijotween  these  and  information  regarding  all  institutional 
and  other  facilities.  I'ho  attitude  of  the  physicians  and  cooperat- 
ing public  health  agencies,  any  systematic  work  already  under- 
taken or  proposed,  the  enforcement  by  local  health  officers  of  the 


Public  Health  ISTuiisiNa  113 

tuberculosis  law  and  any  other  conditions  wliich  may  aifect  the 
local  situation  should  be  known  to  her.  Such  a  survey  will  serve 
as  a  basis  for  the  planning  and  carrying  out  of  her  duties.  She 
may  encounter  either  inertia  or  actual  opposition,  due  to  igno- 
rance or  prejudice  on  the  part  of  individual  patients  and  their 
families  or  of  other  members  of  the  community.  Kegard  for 
racial,  religious  and  local  customs  is  necessaiy ;  in  order  to  accom- 
plish results  —  and  really  large  and  important  results  cau  and 
should  be  obtained  —  it  is  essential  that  she  exercise  good  judg- 
ment, tact,  patience  and  kindness  in  addition  to  her  knowledge 
and  skill. 

DiscovEEY  or  Cases* 

The  nurse  should  obtain  from  the  health  officer  a  list  of  all 
reported  cases  of  tuberculosis ;  such  report  is  required  of  all  physi- 
cians, and  the  local  health  officer  is  obliged  to  keep  a  con- 
fidential register  of  cases.  Since  these  records  are  open  to 
inspection  only  by  the  health  authorities  of  the  State  and  the  city, 
town  or  village  concerned,  except  by  special  authorization  of 
the  State  Commissioner  of  Health,  the  nurse,  if  not  employed 
by  or  operating  under  the  local  health  authorities,  should  request 
such  authorization  from  the  State  Department  of  Health  through 
a  responsible  officer  of  the  organization  employing  her. 
The  nurse  must  not  publish  or  divulge  for  publication  oc 
communicate  to  any  other  person  the  identity  of  the  persons 
to  whom  such  reports  or  registers  relate.  From  the  local  registrar 
of  vital  statistics  a  3-5  year  list  of  deaths  from  tuberculosis  should 
be  obtained,  f 

The  ratio  between  the  number  of  reported  cases  and  of  deaths 
should  be  studied.  If  it  is  found  that  the  number  of  deaths  equals 
or  exceeds  the  number  of  reported  cases  it  can  be  properly  assumed 
that  there  are  a  large  number  of  luireported  and  concealed  cases, 
in  view  of  the  fact  that  we  estimate  that  at  a  given  time  there  are 


*  Since  going  to  press  more  effective  and  desirable  methods  of  discovering 
cases  by  means  of  surveys  with  clinics  have  been  instituted.  A  special 
pamphlet  on  the  subject  will  be  prepared  and  issued. 

7  On  application  the  State  Department  of  Health  will  furnish  to  all  duly 
authorized  nurses  lists  of  cases  and  deaths,  spot  maps  and  other  necessary 
and  useful  data  and  information  regarding  the  local  situation. 


114  State  Department  of  Health 

8  active  cases  to  every  death.  This  assumption  is  also  proper  if 
this  number  is  smaller  than  would  be  expected  from  the  size  and 
character  of  the  community. 

School  teachers,  settlement  workers,  clergymen,  attendance  offi- 
cers, juvenile  court  officers,  employers  of  labor,  etc.,  often  can 
and  should  advise  the  nurse  of  cases  known  to  or  suspected  by  them. 
In  some  instances  a  house  to  house  canvass  may  be  necessary ;  but 
this  should  be  undertaken  guardedly  and  only  with  the  knowledge 
of  the  health  officer  and  the  consent  of  the  physicians  in  attend- 
aace  upon  suspected  cases. 

The  next  step  is  to  visit  all  reported  cases,  ascertain  their 
general  status,  discover  whether  they  have  been  admitted  to  or 
returned  from  a  hospital  or  sanatorium,  or  have  moved,  changed 
physicians,  evaded  oversight  or  died,  and  bring  the  living  under 
supervision  if  necessary.  Before  making  such  visits  the  nurse 
should  obtain  the  cooj)eration  of  the  health  officer  and  of  the 
physicians;  she  should  call  upon  the  latter  and  obtain  from 
them  the  necessary  data  concerning  their  "  private  "  tuberculosis 
cases  or,  if  necessaiy,  arrange  to  visit  such  patients  for  this 
purpose.  She  should  discuss  with  the  physician  the  need  for 
and  desirability  of  her  visitation  of  patients  not  reporting 
frequently  to  the  physicians  and  of  families,  in  which  there  has 
been  a  death  from  tuberculosis,  in  order  to  obtain  data  as  to 
the  physical  condition  of  the  remainder  of  the  family.  She 
should  offer  to  visit  positive  or  suspected  cases  or  former 
tuberculosis  patients  to  ascertain  their  present  status  and  to  urge 
thoir  reexamination.  It  is  essential  that  the  nurse  avoid  any 
actions  which  may  meet  with  the  disapproval  of  the  physician 
whose  consent  and  cooperation  should  be  obtained  in  advance. 
It  is  inadvisable  to  visit  a  home  immediately  after  the  death  or 
burial  of  a  patient;  a  wait  of  one  week  at  least  is  desirable. 
Where  tlie  necessaiy  data  may  Ix^  o.btaiiu^d  from  the  health 
officer,  attending  physician,  other  visiting  nurses,  county  welfare 
agent,  social  service  agent,  etc.,  a  honse  visit  will  bo  unnecessary. 
Where  the  family  is  being  called  on  by  another  nurse  the  data 
should  be  obtained  from  her  if  possible;  otherwise  the  latter 
should     introduce     the    nurse     making     the     survey.        Eveiy 


Public  Health  ]!!^ursino  115 

endeavor  should  be  made  to  have  all  suspected  cases 
examined  to  determine  whether  they  have  tuberculosis. 
This  should  likewise  be  done  with  all  "  contacts/'  including 
all  members  of  the  household,  or  of  the  factory,  mill,  or  shop 
who  have  been  exposed  by  living  or  working  with  the  known 
case  or  cases.  The  individual  in  question  should  first  be  referred  to 
his  usual  attending  or  family  physician.  If  he  can  not  afford  to 
pay  the  physician  for  his  services  the  latter  should  be  informed  of 
this  fact ;  very  often  he  will  make  an  examination  without  charge. 
If  this  is  not  possible,  the  case  should  be  referred  for  examination 
to  the  dispensary,  if  there  is  one,  or  to  the  county  tuberculosis 
hospital  superintendent.*  In  counties  where  no  tuberculosis 
hospital  exists  the  case  should  be  referred  to  any  competent 
examiner.  Under  the  provision  of  regulation  42-a  of  chapter  II, 
Sanitary  Code,  the  local  health  ofiicer  is  required,  if  the  alleged 
case  has  not  been  previously  reported  to  him  as  having  tuber- 
culosis, to  take  proper  measures  to  determine  whether  there  is 
reason  to  believe  such  person  is  affected  with  pulmonary  tuber- 
culosis. Suspects  who  refuse  to  consult  a  physician  and  to 
observe  the  necessary  precautions  should  be  complained  of  in 
writing  to  the  local  health  officer. 

Suspected  cases  and  those  who  have  been  exposed  should  be 
kept  under  observation  until  the  medical  adviser  considers  them 
either  positive  or  no  case.  If  the  suspected  case  has  been  referred 
to  a  dispensary  by  a  lay  social  worker,  the  nurse  should  not 
assume  charge  of  the  case  unless  the  diagnosis  is  positive  and  the 
dispensary  itself  requests  the  service  of  a  nurse.  If  the  social 
worker  continues  to  visit  the  family,  she  should  attend  to  the 
matter  of  obtaining  reexaminations,  calling  on  the  public  health 
nurse  when  necessaiy.  If  the  nurse,  however,  must  visit  the 
family  for  other  purposes  she  assumes  the  sanitary  over- 
sight of  the  patient  if  no  physician  is  in  attendance,  and  the 
local  health  officer  has  delegated  the  nurse  to  act  for  him  in  main- 
taining such  oversight.     If  a  physician  is  in  attendance  the  nurse 


*  Section  47  of  the  County  Law  provides  that  the  board  of  managers  of 
county  tuberculosis  hospitals  shall  cause  to  be  examined  by  the  superintendent 
or  one  of  his  medical  staff  suspected  cases  of  tuberculosis  reported  to  it  by  the 
county  nurse,  or  by  physicians,  teachers,  employers,  heads  of  families  or  others. 


116  State  Department  of  Health 

acts  undei  his  direction.  If  the  nui'se  continues  her  visits  she 
should  secui'e  the  examination  and  reexamination  of  the  contacts 
until  a  definite  disposition  is  made  of  them.  If,  however,  the 
patient  leaves  home  or  dies,  and  there  is  available  another  worker 
who  is  still  visiting  the  family,  the  latter  should  assume  the 
follow  up  work. 

Examination  of  Spttium 

In  eveiy  instance  where  an  individual  has  had  a  cough  per- 
sisting for  one  month  or  longer  the  nurse  should  endeavor  to  have 
an  examination  of  the  sputum  made.  The  necessary  jars  and 
blanks  may  be  obtained  from  the  local  bealth  officer  or  labora- 
tory and  the  examination  made  either  at  the  local  or  state  laborar 
toiy.  Full  infoxmation  as  to  obtaining  sputum  and  data  for 
forwarding  of  specimens  (which  last  should  be  done  through  the 
health  officer),  is  given  on  the  blanks.  In  this  connection  it  is 
necessary  to  emphasize  the  fact  that,  while  the  discovery  of 
tubercle  bacilli  in  the  sputum  is  positive  evidence  of  the  existence 
of  the  disease,  failure  to  find  them  does  not  negative  its  presence. 
Repeated  examinations,  at  least  three  and  often  more,  are  neces- 
saiy  before  a  definite  statement  as  to  the  patient's  not  being 
tuberculous,  based  on  sputum  findings,  may  be  made.  It  should 
be  remembered  that  when  tuberculosis  is  present  a  positive 
diagnosis  can  and  should  be  made  by  a  competent  examiner  even 
though  the  sputum  be  negative,  since  some  advanced  cases  do  not 
expectorate  tubercle  bacilli.  It  is  of  course  obvious  that  while  a 
case  with  negative  sputum  may  not  be  dangerous  to  others,  such 
sputum  may  at  any  future  time  contain  the  bacilli  and  the  patient 
thu?  becomes  a  menace. 

Disposition  of  Patients 

When  it  has  been  determined  that  an  individual  has  active 
tuberculosis  his  disposition  requires  prompt  attention.  In  con- 
sidering this  matter  it  should  be  borne  in  mind  that  the  interests 
of  the  individual  and  tbose  of  his  family  and  of  the  community 
at  large  are  best  served  by  having  the  patient  sent  to  a  sanatorium 
or  hospital.  For  the  individual,  in  the  vast  majority  of  cases,  this 
assures  the  best  treatment  and  therefore  the  greatest  opportunity 


Public  Health  Nuesing-  117 

for  an  arrest  in  early  cases,  or  a  prolongation  of  life  in  some 
comfort  for  those  witi.  advanced  disease.  Furthermore,  the  les- 
sons learned  at  the  sanatorium  by  the  patient  with  early  disease, 
even  though  he  does  not  stay  until  it  is  entirely  arrested,  will  be  of 
great  assistance  to  him  in  completing  the  "  cure  "  at  home.  The 
discharged  patient  is  very  often  an  effective  and  serviceable  health 
teacher  and  missionary.  From  the  standpoint  of  the  family,  the 
patient's  presence  at  home  would  entail  avoidable  and  unnecessary 
hardships,  which  are  in  great  part  obviated  by  his  admission  to 
an  institution.  This  also  removes  a  source  of  infection  from  the 
family  and  the  community. 

Efforts  should  be  made  to  have  every  case  admitted  to  an  institu- 
tion if  possible.  Unfortunately  existing  institutional  facilities 
are  not  adequate  to  care  for  all  cases.  In  IsTew  York  State,  for 
instance,  the  provision  of  one  bed  for  each  annual  death  from 
the  disease  is  being  secured.  It  is  obvious  that  with  such  pro- 
vision (the  best  now  obtainable),  all  cases  can  not  be  accom- 
modated. However,  there  are  many  tuberculous  patients  who 
either  can  not  or  will  not  enter  an  institution  because  of  per- 
sonal or  family  opposition,  economic  and  financial  difficulties, 
etc.  The  following  general  rules  regarding  hospitalization  of 
tuberculosis  patients  are  believed  to  be  practicable.  If  it  is 
not  possible  to  have  all  cases  admitted,  all  open  cases  where 
there  are  children  in  the  household  should  be  transferred 
to  an  institution  at  once.  Home  treatment  may  be  substi- 
tuted when  there  are  no  children  in  the  household  and  when 
it  is  possible  to  obtain  facilities  at  home  for  the  proper  out- 
door treatment  under  favorable  hygienic  conditions.  If  home 
treatment  is  to  be  successful,  adequate  nursing  and  medical  super- 
vision over  a  sufficiently  long  period,  with  a  patient  and  family 
intelligent  enough  to  carry  out  all  details,  are  essential.  Any 
tuberculous  person  who  either  will  not  or  can  not  so  conduct 
himself  as  not  to  be  a  menace  to  others  should  be  forcibly  removed 
to  a  hospital,  as  provided  for  in  section  326-a  of  the  Public  Health 
Law  (see  pamphlet,  "  Compilation  of  Tuberculosis  Laws,"  fur- 
nished by  the  State  Department  of  Health) .  Where  hospital  treat- 
ment is  not  available,  the  patient  should  be  admitted  to  a  camp,  if 
there  be  one.  If  he  remains  at  home  he  should  be  kept  under  the 
observation  of  a  private  physician  or  a  dispensary,  or  a  tubercu- 


118  State  Depaetment  of  Health 

losis  class.  Xo  disposition  of  any  patient  should  be  made  by 
the  nurse  without  first  securing  the  advice  and  consent  of  either 
the  regular  medical  attendant,  the  dispensary  physician  or 
the  health  officer.  This  is  essential  as  there  may  exist  certain 
contraindications  such  as  complications  which  would  make  high 
altitude  or  removal  inadvisable.  Children  suffering  with  pulmon- 
ary tuberculosis  should  be  sent  to  an  institution,  as  also 
should  those  who  have  bone,  joint,  and  gland  tuberculosis.  Unfor- 
tunately existing  institutional  facilities  for  the  care  of  tuber- 
culous children  are  very  limited;  they  should  be  extended. 
Those  children  who,  while  not  actively  tuberculous  are  neverthe- 
less weak  and  poorly  nourished,  whose  home  conditions  are 
undesirable,  and  who  have  been  extensively  exposed  to  the  dis- 
ease, should,  if  possible,  receive  care  in  a  preventorium  camp  or 
open  air  class.  The  adult  who  is  "  run-down  "  can  also  derive  a 
great  deal  of  benefit  from  preventorium  care  where  such  is  avail- 
able. 

In  the  case  of  patients  discharged  from  a  sanatorium  as 
arrested,  or  of  those  in  whom  the  disease  is  inactive,  the  matter 
of  after-care  should  receive  the  nurse's  attention.  These  indi- 
viduals require  close  medical  and  nursing  supervision  in  order 
that  the  good  results  which  have  been  obtained  may  continue. 
The  details  as  to  rest,  outdoor  treatment,  occupation,  etc.,  depend 
on  individual  cases  and  should  be  prescribed  by  the  physician. 
It  is  advisable  that  the  patient  be  examined  once  a  month;  he 
should  be  informed  as  to  the  possibility  of  his  having  to  return 
to  an  institution  on  the  appearance  of  evidences  of  a  relapse. 

Home    Supervision 

Tlie  patient  who  remains  at  home  obviously  requires  medical 
and  sanitary  attention,  and  in  many  instances,  material  relief. 
The  first  of  these  should  he  given  by  a  private  physician  or  a 
dispensaiy  as  the  circumstances  necessitate  and  allow.  Under 
the  New  Yoxk  statute  sanitary  care  must  be  given  either 
by  the  physician  or  by  the  health  officer.  The  phj^sician  in 
reporting  a  case  of  tuberculosis  is  required  to  signify  his  will- 
ingness to  perform  this  duty ;  if  he  will  not  or  can  not  maintain 
sanitary  supervision  this  devolves  upon  the  health  officer.  If 
the  nurse  is  acting  under  the  latter's  direction  this  duty  may  be 


Public  Health  Cursing  119 

delegated  to  her,  in  which  ease  she  exercises  full  sanitary  control 
independently  of  the  attending  physician,  who  may,  however,  con- 
tinue to  attend  the  patient.  Physicians  in  attendance  upon 
tuberculous  cases  often  request  the  services  of  a  public  health 
nurse  for  the  j)urpose  of  maintaining  sanitary  supervision.  Under 
these  conditions  the  nurse  acts  under  the  direction  of  the  physician 
in  advising  and  instructing  the  patient  and  his  family.  If  the 
physician  is  only  nominally  in  charge  or  unwilling  or  unable  to 
maintain  sanitary  supervision,  this  duty  devolves  upon  the  nurse 
as  the  representative  of  the  health  officer.  A  health  officer  has 
authority  to  have  all  repoa-ted  cases  of  tuberculosis  in  his  juris- 
diction visited  by  a  public  health  nurse. 

The  public  health  nurse  employed  by  public  authorities  can 
make  no  distinction  between  the  poor  and  those  able  to  pay  in 
providing  sanitary  insti^ction,  since  this  is  intended  to  promote 
the  public  health  generally. 

The  public  health  nurse's  work  includes  sanitary  instruction 
and  advice  as  to  the  patient's  well  being,  subject  to  the  orders  of 
the  attending  physician,  if  there  be  one.  Her  functions  in  the 
home  are  primarily  of  a  sanitaiy  natui'e;  nursing,  as  such, 
is  not  to  l>e  given  except  insofar  as  it  may  be  necessary  for 
purposes  of  instruction,  in  an  emergency,  or  to  gain  the  con- 
fidence and  good  will  of  the  patient  and  family.  Where  pro- 
longed bedside  nursing  is  necessary,  a  private  nurse  should  be 
secured,  if  the  patient  can  afford  to  pay,  and  if  not  a  visiting 
nurse's  association  should  be  requested  to  supply  such  service. 

The  statute  requires  that  every  reported  case  of  tuberculosis  be 
furnished  with  a  circular  of  information  regarding  the  best 
method  of  treatment  of  tuberculosis  and  of  the  precautions  neces- 
sary to  prevent  its  transmission  to  others.  Such  circulars  are 
supplied  by  the  local  health  officer  through  the  physician,  if  there 
is  one  in  attendance,  or  else  direct  to  the  patient. 

"While  the  circular  of  information  is  very  useful  and,  theo- 
retically, should  supply  the  patient  and  his  family  with  all  the 
necessary  information,  practically  it  is  necessary  that  the  nurse 
give  personal  instructions  and  demonstrations.  This  should 
include  information  regarding  the  nature  of  the  disease  and  the 
danger  of  its  spread  to  others,  the  method  of  proper  disposal  of 


120  State  Depaetmext  of  Health 

sputum  or  other  infectious  discharges,  both  in  the  home  and 
when  abroad,  keeping  the  hands  free  from  infectious  material, 
avoiding  the  contamination  of  objects  which  may  be  used  by 
others,-  the  avoidance  of  unguarded  coughing  and  sneezing  and 
of  putting  fingers  in  the  mouth,  and  the  prevention  of  contact 
infection  in  the  family.  The  danger  of  having  the  patient  pre- 
pare food  to  be  eaten  by  others  should  be  stressed,  as  should  also 
the  danger  of  working  in  the  same  room,  eating  at  the  same  table, 
sleeping  in  the  same  bed,  or  using  the  same  dishes.  The  official 
procedures  and  precautions  which  are  given  in  a  preceding  sec- 
tion must  be  followed.  The  nurse  should  also,  under  the  super- 
vision of  the  physician,  amplify  the  latter's  instructions  as  to 
mode  of  life  and  diet,  and  help  arrange  for  outdoor  sleeping 
facilities,  clothing,  baths,  etc.  She  should  not  make  any  change 
in  the  patient^s  diet,  except  upon  the  physician's  advice  and  con- 
sent. If  there  is  no  physician  in  attendance  and  the  nurse  is  tak- 
ing entire  charge  of  the  case,  she  should  appeal  to  the  health 
officer  in  matters  of  a  medical  nature  in  which  she  feels  she  needs 
assistance.  AVhen  giving  instruction  it  is  advisable  to  select  some 
responsible  member  of  the  household  and  teach  slowly  and  care- 
fully, giving  practical  demonstrations.  It  is,  of  course,  necessary 
that  the  nurse  make  certain  that  her  teachings  are  being  followed ; 
she  should  make  corrections  and  changes'  where  and  when 
necessary. 

In  order  to  allow  for  the  proper  carrying  out  of  the  essential 
precautions,  the  health  officer  is  required  to  advise  the  physician 
as  to  what  he  has  on  hand  in  the  way  of  sputum  cups,  paper  nap- 
kins, disinfectants,  etc.,  and  to  provide  the  latter  with  a  requisi- 
tion form,  which  when  properly  filled  out,  must  be  honored  by 
the  health  officer  and  the  supplies  requested  furnished  in  the 
amount  deemed  necessary. 

Medical  emergencies  or  incidents  which  may  arise  in  the  course 
of  the  nurse's  visits  to  the  home  include  the  occurrence  of  hem- 
on-hagc,  pneumothorax,  possibly  confinement  of  the  patient,  or  the 
occurrence  of  communicable  diseases  other  than  tuberculosis  in 
the  household. 

In  the  case  of  hemorrhage  the  nurse  should  remember  that  in 
many  instances  the  bleeding  will  stop  without  or  in  spite  of  any 
treatment  which  may  be  instituted.     If  the  lioinorvhnge  be  due  to 


Public  Health  Nuksing  121 

the  erosion  of  a  large  artery  in  a  cavity  or  into  a  bronclius  the 
patient  may  bleed  to  death.  The  nurse  should  reassure  the 
patient,  both  by  words  and  actions,  acting  calmly,  quietly 
and  confidently.  A  physician  should  be  notified,  the  patient  put 
to  bed  in  a  semi-sitting  position,  with  sufiicient  support  by  means 
of  pillows  under  his  back  and  head  to  maintain  this  position, 
and  admonished  to  remain  absolutely  quiet  and  not  even  talk 
unless  essential.  Cracked  ice  may  be  given  by  mouth  continuously 
and  cold  in  the  form  of  an  ice  bag  applied  to  the  chest  (heart). 
The  nurse  should  not  leave  the  patient  until  the  physician  arrives. 

Spontaneous  pneumothorax  in  tuberculous  patients  is  due  to  the 
giving  way  of  the  pleura  and  the  entrance  of  air  from  the  lungs 
into  the  pleural  cavity.  If  this  occurs  suddenly,  the  patient  will 
complain  of  severe  pain  in  the  chest  with  a  sensation  of  some- 
thing having  given  way  and  will  show  evidences  of  shock  with  a 
rapid,  feeble  pulse,  hurried  and  labored  breathing,  great  short- 
ness of  breath,  a  sense  of  sufi^ocation,  and  a  clammy  skin  which  may 
be  pale  or  bluish.  The  nui"se  should  call  a  physician  at  once. 
The  patient's  position  varies,  it  sometimes  being  impossible  for 
him  to  Ue  down  owing  to  the  sense  of  suffocation  experienced. 
When  the  condition  comes  on  more  gradually  the  symptoms  are 
not  so  sudden,  severe  and  pronounced  Those  cases  which  recover 
usually  have  the  pleural  cavity  infected  with  pus  forming 
organisms. 

When  a  communicahle  disease  other  than  tuberculosis  occurs  in 
the  family,  the  medical  disposition  of  the  case  will  depend  upon 
the  physician  in  charge,  the  health  ofiicer,  or  the  nurse  if  she 
is  authorized  to  act.  Wherever  possible  such  patient  should  be 
promptly  removed  to  a  hospital.  The  Sanitary  Code  (Chapter 
II)  makes  specific  provision  for  either  the  isolation  or  removal  of 
cases  of  certain  communicable  diseases.  In  the  case  of  diphtheria, 
scarlet  fever  or  typhoid  fever  occurring  in  a  hotel,  lodging  or 
boarding  house,  the  health  officer  having  jurisdiction  is  required 
either  to  have  the  patient  removed  to  a  suitable  hospital,  if  avail- 
able, or  else  to  isolate  the  case  on  the  premises  if  this  can  be  done 
safely,  the  other  inmates  to  be  removed  from  the  premises  if 
necessary.  When  required,  the  municipal  authorities  must  make 
provision  for  the  medical  and  nursing  care  of  such  cases  remaining 


122  State  Department  of  Health 

on  the  premises  mentioned.  In  those  localities  where  either  a  pri- 
vate or  public  agency  employs  visiting  nurses  for  the  specific  pur- 
pose of  attending  cases  of  infectious  or  communicable  diseases, 
it  will  usually  be  advisable  for  the  tuberculosis  nurse  to  with- 
draw temporarily  from  the  family  and  permit  the  communicable 
disease  nurse  to  take  charge  of  both  the  tuberculous  and  other 
cases. 

Maternity  Cases  in  Family 
When  the  patient  or  some  other  member  of  the  family  is  to  be 
confined,  the  disposition  of  the  case  rests  with  the  physician,  and 
if  there  is  none,  with  the  nurse  in  charge.  It  is  advisable  that  the 
patient  be  removed  to  a  maternity  or  other  hospital.  The  tuber- 
culosis nurse  should  not  be  expected  to  attend  the  patient  during 
confinement;  a  physician,  midwife,  or  visiting  nurse  from  a 
public  or  private  agency  should  be  secured  if  possible. 

Dental    Service 

Dental  service  is  essential  but  may  often  be  difiicult  to  obtain, 
either  because  the  dentist  refuses  to  handle  infectious  cases,  or 
can  not  or  will  not  give  free  service  to  the  indigent,  or  both.  In 
order  to  overcome  the  first  objection  it  is  advisable  to  obtain  a 
certificate  from  the  health  ofiicer  as  to  the  patient's  being  non- 
infectious, i.  e.,  not  expectorating  tubercle  bacilli.  A  dentist 
willing  to  give  his  services  free  should  be  found;  if  this  be 
impossible,  efforts  should  be  made  to  obtain  funds  from  some 
charitable  individual  or  agency.  It  may  be  necessary  to  send 
the  infectious  patient  to  another  locality  to  obtain  the  required 
service. 

The  Family  in  an  Insanitary  Hoitse 

For  the  family  in  an  insanitary  house  one  of  two  procedures 
is  possible.  The  ninso  may  either  attempt  to  have  the  conditions 
corrected,  or  failing  in  this  she  may  take  steps  to  bring  about  the 
removal  of  the  family  to  a  better  home.  For  the  first  purpose,  she 
should  make  complaint  in  writing  directly,  if  so  authorized,  or 
else  through  her  superior,  to  the  department  or  bureau  having 
jurisdiction.  When  removal  is  deemed  necessary,  if  the  family 
is  being  assisted  or  maintained  by  a  charitable  agency,  recom- 
mendations    to    and    cooperation    with     the    latter    should    be 


Public  Health  Xursing  123 

made  and  given.  The  consent  of  the  health  officer  is  not 
required  for  such  removal;  it  must,  however,  be  reported  to  him 
within  24  hours  of  its  occurrence  so  as  to  allow  for  the  necessary 
cleansing,  renovation,  or  disinfection.  In  case  a  representative  of 
a  charitable  agency  desires  to  remove  a  family  which  is  under  the 
supervision  of  a  nurse,  the  rules  of  the  agency  will  govern;  but 
it  is  best  that  the  charity  agent  consult  with  the  nurse  or 
health  officer,  who  may  be  able  to  advise  as  to  the  desirability 
of  the  new  premises.  The  reporting  of  the  removal  to  the  health 
officer  is  required  of  the  agent  who  should  also  inform  the  nurse 
so  as  to  save  her  a  trip  to  the  wrong  address. 

Relief 
As  is  generally  known,  tuberculosis  is  in  many  cases  compli- 
cated by  poverty.  This  is  unfortunate,  not  only  because  of 
its  unfavorable  influence  in  connection  with  the  development  of 
active  disease,  but  also  in  that  it  may,  unless  relieved,  militate 
against  the  patient's  receiving  proper  care  and  treatment. 
When  the  breadwinner  of  the  family  is  affected,  whether  he  go 
to  the  hospital  or  remain  at  home,  the  difficulties  are  obvious. 
In  any  case,  the  securing  of  the  proper  appurtenances,  such  as 
cure  chairs,  blankets,  proper  clothing,  medicines,  and  food, 
presents  a  prol)lem.  Assistance  rendered  without  cost  either  to 
remedy  or  alleviate  social  or  physical  defects  is  denomi- 
nated relief.  This  may  be  medical,  consisting  of  free  medical, 
hospital  or  dispensary  care,  or  material,  including  shelter,  food  or 
clothing.  It  may  be  secured  through  residence  in  an  institution, 
when  it  is  named  indoor  relief.  Outdoor  relief  is  that  provided 
outside  of  a  hospital.  The  sources  from  which  assistance  may  be 
obtained  are  either  public  or  private  and  vary  from  a  single 
individual  to  an  organization  or  institution.  Which  of  these  are 
available  in  a  given  community  usually  depends  on  its  size, 
resources  and  enlightenment.  It  is  not  intended  to  go  into 
details  here  regarding  the  securing  and  administering  of  relief. 
In  order  to  be  effective  relief  must  be  adequate,  i.  e.,  sufficient 
both  in  kind  and  amount.  It  should  also  be  timely  and 
administered  so  as  to  assist  the  recipient  without  pauperizing 
him  or  making  him  a  helpless  dei>endent,  which  he  might  other- 
wise not  become.     A  good  knowledge  of  the  principles  governing 


124:  State  Department  of  Health 

charitable  work,  combined  with  good  judgment,  are  essential; 
the  public  health  nurse  may  have  the  latter,  but  not  necessarily 
the  former.  For  this  reason,  and  also  because  it  is  more  advan- 
tageous for  all  concerned,  the  nurse  should  not  administer  relief 
if  there  is  any  existing  agency  which  can  do  so.  If  the  latter 
does  not  function  satisfactorily,  the  nurse  should  make  efforts 
to  discover  the  reason  rather  than  to  administer  relief  herself. 
Evea  when  private  individuals  provide  relief  it  may  be  possible 
to  have  them  attend  to  the  details  of  its  administration.  The 
nurse  should  know  the  charitable  organizations  in  the  community 
and  cooperate  with  them;  and  while  not  directing  the  relief 
work,  she  should  make  recommendations  to  those  who  are  doing 
so.  In  an  emergency  promptness  of  action  is  essential.  When 
a  lack  of  food,  fuel  or  clothes,  is  found,  the  central  office  or 
nearest  agent  of  an  organization  should  be  communicated  with 
immediately. 

Very  often  in  localities  where  there  is  no  relief  organization, 
one  may  be  initiated  and  established  as  the  result  of  the  nurse's 
request  for  aid  from  different  private  individuals. 

Social  Wokk  oe  the  Nukse 

When  a  social  worker  is  not  available  it  becomes  necessary  for 
the  public  health  nurse  to  perform  duties  of  a  social  character, 
which  may  go  so  far  as  to  involve  a  complete  readjustment  of 
family  conditions.  Certain  forms  of  social  work,  e.  g.,  mothers^ 
meetings,  special  classes  for  selected  cases  and  clubs  for  boys  and 
girls  are  really  legitimate  preventive  activities. 

COOPEEATION   and   DiVISION    OF   DuTIES   BeTWEEN   THE   SeVEEAL, 
WOEKEKS  IN  A   TuBEECULOUS  FaMILY 

From  what  has  been  said  it  is  evident  that  there  may  be  one  or 
more  of  a  number  of  individuals  visiting  a  tuberculous  famUy 
for  purposes  concerned  with  the  presence  of  the  disease.  In  order 
that  the  interests  of  the  individual  and  his  family  and  those  of 
the  community  at  large  may  best  be  served,  it  is  essential  that 
the  scope  of  duties  of  each  of  these  be  clearly  defined.  This 
matter  has  been  previously  indicated,  what  follows  is  supple- 
mental. 


Public  Health  Nursiitg  125 

The  provisions  of  the  code  of  medical  ethics,  which  prescribe  a 
standard  of  conduct  for  physicians  in  their  relation  with  one 
another  and  with  the  public,  must  be  carried  out  insofar  as  they  are 
applicable.  The  nurse  visiting  a  case  attended  by  a  physician, 
is  essentially  the  latter's  assistant;  if  the  nurse  is  employed  by 
the  State  or  a  municipality  she  also  usually  represents  the  health 
officer  or  other  authority  under  whose  direction  she  acts.  Where 
a  district  or  poor  physician  attends  a  case,  his  relation  to  the 
patient  is  the  same  as  that  of  a  paid  private  physician,  and 
he  is  entitled  to  the  same  courtesies.  Sometimes  technical 
and  other  considerations  modify  the  situation.  For  instance, 
the  physician  may  be  required  to  make  only  one  visit  or 
to  attend  the  patient  for  a  specified  time  or  to  attend  only  such 
patients  as  consult  him  upon  the  written  order  of  a  public  author- 
ity during  the  period  specified  by  such  authority.  These  details 
may  affect  the  relations  of  the  nurse  or  social  worker  visiting 
the  family  to  such  district  physician;  if  deemed  advisable,  they 
may  refer  such  patients  to  other  physicians,  or  to  dispensaries, 
either  with  his  consent,  or  when  his  period  of  attendance  expires. 
In  some  communities  the  system  which  provides  medical  attention 
to  the  poor  does  not  always  operate  satisfactorily,  and  the  nurse 
may  be  justified  in  acting  upon  her  own  initiative.  It  is  well  for 
the  nurse  to  be  informed  as  to  the  precedures  necessary  to  secure 
the  services  of  a  charity  physician  so  that  in  an  emergency  there 
may  be  no  misunderstanding  or  technical  evasion  by  anyone  con- 
cernefl.  As  an  illustration  of  the  differences  in  procedures,  it  may 
be  stated  that  in  some  localities  the  physicians  may  not  be  required 
to  respond  to  an  emergency  call  except  upon  a  police  order.  In 
other  districts  it  may  be  necessary  for  the  patient  himself  or  a 
member  of  his  family  to  make  application  in  person  for  medical 
service. 

Many  poor  patients  are  not  actually  seen  by  any  medical  worker 
except  the  nurse,  although,  nominally  at  least,  there  should  be  a 
physician  in  attendance.  If  there  is  none,  or  if  he  permits  the 
nurse  to  act  for  him,  then  all  sanitary  and  medical  problems  in 
the  family  come  definitely  within  her  province.  If  a  responsible 
charitable  agency  is  interested  all  economic  matters  in  the  family 


126  State  Department  of  Health 

are  quite  as  definitely  within  its  province.  When,  on  the  other 
hand,  there  is  a  physician  and  lay  social  worker  but  no  nurse 
attending,  the  medical  direction  and  disposition  of  the  patient 
rests  entirely  with  the  physician,  unless  the  health  officer  has  cause 
for  interference,  in  which  instance  the  latter  can  have  the  case 
visited  by  a  nurse ;  such  procedure  is  often  necessar)^  and  is  justi- 
fied if  the  physician  is  only  nominally  in  attendance  or  does  not 
maintain  sanitary  oversight.  Should  the  necessary  cooperation 
between  the  social  worker  and  the  nurse  visiting  a  tuberculous 
family  become  impossible,  or  should  the  withdrawal  of  either 
become  advisable,  it  is  the  nurse  who  should  continue  to  visit  the 
family.  She  can  not  discontinue  her  visits,  if  she  is  acting 
under  the  direction  of  a  public  health  authority,  without  con- 
sent of  such  authority.  The  health  officer  has  the  right  to  cause 
any  reported  case  of  tuberculosis  under  his  jurisdiction  to  be 
visited  by  a  public  health  nurse,  under  which  circumstances 
the  latter  acts  as  the  health  officer's  representative  in  the  enforce- 
ment of  the  law,  and  the  continuance  of  her  activities  is  essential. 
In  those  cases  where  several  different  agencies  employ  nurses 
for  field  work  it  is  often  necessary  to  exercise  care  in  order  to 
prevent  duplication  of  effort.  The  public  health  nurse  acting 
under  the  direction  of  local  or  state  health  authorities  has  certain 
legal  duties  to  perform,  as  previously  indicated;  these  she  can 
neither  delegate  to  others  nor  neglect.  Where  it  is  necessary 
for  nurses  representing  other  agencies,  such  as  hospitals,  dis- 
pensaries and  tuberculosis  committees,  to  visit  families  in  charge 
of  a  nurse  representing  a  health  authority,  the  ordinary  rules  of 
courtesy  should  be  observed.  The  nurse  primarily  in  charge  of 
the  family  should  be  consulted  first;  she  may  be  able  to  accom- 
plish the  work  or  obtain  the  information  desired,  in  which  case 
no  visitation  by  others  will  be  necessary.  Where  it  is  desirable 
that  the  nurse  from  the  private  or  other  agency  keep  the  patient 
or  family  under  observation  or  visit  them  frequently,  a  plan 
of  cooperation  should  be  agreed  upon  by  all  concerned.  It  may  be 
feasible,  for  instance,  for  the  nurse  representing  the  health  author- 
ity to  make  the  first  visit,  provide  the  first  instruction,  etc.,  and 


Public  Health  N"uRsriirG  127 

make  only  occasional  subsequent  visits,  while  the  other  agencies 
concemed  are  closely  in  touch  with  the  family's  affairs.  Har- 
monious coo]3eration  is  absolutely  essential. 

Other  Forms  of  Tuberculosis 

The  public  health  nurse  usually  visits  only  pulmonary  and 
laryngeal  eases  of  the  disease;  other  forms,  such  as  bone,  menin- 
geal, kidney  and  peritoneal  tuberculosis,  are  not  usually  com- 
municable and  sanitary  supervision  may  not  be  necessary.  It  may 
be  sufficient  for  the  nurse  to  call  occasionally  on  such  families  to 
determine  that  no  other  members  have  suspicious  sjmiptoms  or  are 
affected  with  the  disease.  The  number  of  cases  of  nonpulmonary 
forms  of  the  disease  is  so  large  that  it  is  not  practicable  for  the 
public  health  nurse  to  follow  them  up  or,  in  many  localities,  even 
to  make  any  visitation  of  them.  Such  patients  should  be  removed 
to  institutions  or  be  taken  care  of  by  a  visiting  nurse  from  a 
private  agency  or  settlement  house,  or  community  center.  In 
large  cities  cases  of  bone  and  other  surgical  tuberculosis  may  be 
visited  by  surgical  nurses  from  private  agencies. 

Eight  of  Entrance  and  Inspection 
Eegulation  15  of  chapter  II  of  the  Sanitary  Code  provides 
that  no  person  shall  interfere  with  or  obstruct  the  entrance  to 
any  house  or  building  by  any  inspector  or  officer  of  the  state  or 
local  health  authorities  in  the  discharge  of  his  official  duties,  nor 
shall  any  person  interfere  with,  or  obstruct  the  inspection  or 
examination  of  any  occupant  or  any  such  house  or  building  by  any 
inspector,  or  officer  of  the  state  or  local  health  department  in  the 
discharge  of  his  official  duties.  It  is,  therefore,  obvious  that  the 
public  health  nurse,  in  acting  for  or  under  the  direction  of  a 
local  or  state  health  authority,  has  the  right  to  enter  premises 
and  visit  occupants  when  necessary  to  do  so  in  the  performance 
of  her  duties.  In  some  communities  it  has  been  found  practicable 
for  the  health  officers  to  delegate  their  authority  to  nurses 
employed  by  private  agencies  so  as  to  facilitate  their  work. 

Milk  and  Eggs  for  Tuberculous  Patients 
When  the  nurse  has  milk  and  eggs  available  for  distribution 
to  her  patients  she  should,  in  justice  to  all  concerned,  pursue  a 


128  State  Depaetment  of  Health 

definite  policy  in  her  distribution  o£  suck  food.  Milk  and 
eggs  axe  very  apt  to  be  misused  unless  the  nurse  exercises  care 
and  discrimination.  It  may  be  very  useful  for  her  to  observe 
the  following  rules: 

1  The  patient  and  family  must  be  unable  to  buy  them. 

2  The  patient  must  thoroughly  cooperate  with  the  nurse  and 
observe  her  instructions  —  and  when  the  patient  fails  to  do  so 
the  furnishing  of  milk  and  eggs  should  be  discontinued, 

3  'No  incipient  patient  should  be  given  milk  and  eggs  unless 
there  is  sufficiently  good  reasons  Avhy  he  can  not  go  to  a 
sanatorium. 

4  No  patient  should  be  given  moj-e  than  one  quart  of  milk 
daily  and  one  dozen  eggs  weekly  except  for  special  reasons. 

5  Milk  and  egg-s  should  never  be  given  as  relief  or  as  supple- 
mentary relief. 

6  1^0  distinction  should  usually  be  made  between  classes  of 
patients  with  regard  to  their  supervision  by  private  physicians, 
dispensaries,  tuberculosis  classes  and  health  officers  if  the  super- 
vising agency  approves  the  patienf s  application  for  milk  and 
eggs;  hospital  patients,  however,  should  not  be  eligible. 

7  As  soon  as  the  patient  or  family  is  able  to  buy  milk  and 
eggs  the  free  supply  should  be  stopped  and  they  should  be  advised 
of  the  fact. 

8  Application  for  milk  and  eggs  should  be  made  in  writing  by 
the  patient  or  head  of  the  family,  and  it  should  be  agreed  that 
they  will  be  used  only  as  directed  by  the  physician. 

9  Milk  and  eggs  should  not  be  given  to  any  patient  who  is  not 
under  the  supervision  of  a  public  health  nurse  who  has  agreed 
to  assist  in  the  enforcement  of  these  rules. 

10  In  supplying  milk  and  eggs  patients  should  be  given 
preference  as  follows: 

(a)  Tuberculous  children  under  16  years  of  age; 

(b)  Advanced  patients  who  can  not  assimilate  other  food ; 

(c)  Incipient  patients; 

(d)  All  other  tuberculous  patients. 

Organizhstg  a  Local  Tuberculosis  Campaign 
It  may  be  that  the  nurse  will  find  that  little  or  no  antitubercu- 
losis work  hns  been  done  in  certain  communities  and  it  is  then  her 


Public  Health  Kukspng  120 

proper  function  to  stimulate  such  work.  It  is  usually  advisable 
that  different  individuals  and  agencies,  such  as  physicians,  health 
authorities,  business  men,  women's  clubs,  clergymen  and  the  press 
be  interested,  the  last  two  being  able  to  speak  on  the  subject 
from  the  pulpit  and  through  the  newspapers,  respectively. 
A  tuberculosis  exhibit  should  be  given  and  a  tuberculosis  society 
formed.  A  dispensary  should  be  established  with  a  well  qualified 
physician  and  nurse  attached  to  it;  if  advisable  and  feasible,  a 
camp  should  be  started.  Though  in  the  beginning  it  may  be 
necessary  to  obtain  private  funds  for  these  purposes,  it  is  usually 
not  difficult  to  have  the  municipality  later  supply  the  fund  and 
take  charge  of  the  activities. 

Eecoeds 
Records  are  of  secondary  importance ;  they  are  necessary,  how- 
ever, for  obvious  reasons.  They  should  be  simple  and  at  the 
same  time  sufficiently  complete.  The  State  Department  of  Health, 
and  the  State  Charities  Aid  Association  Tuberculosis  Committee, 
in  cooperation,  have  prepared  a  set  of  records  intended  for  the 
use  of  county  tuberculosis  nurses,  but  adaptable  with  slight  modi- 
fications for  other  nurses  engaged  in  tuberculosis  work.  Complete 
sets  of  these  may  be  purchased  from  the  latter  organization. 
5 


ir.O  Statk   Dei'ai;tmi  XT  oi-  TTkai.th 


CHAPTER    IX 

Cooperation  of  Health  and  Educational  Authorities  in  the  Con- 
trol of  Communicable  Diseases 

School  medical  iuspcction  lias  two  definite  aims;  first,  the  early 
recognition  and  exclusion  from  school  of  children  suffering  from 
acute  communicahle  disease,  as  a  prime  factor  in  the  control  of 
local  epidemics;  second,  the  recognition  of  physical  nnd  mental 
defects  and  ahnormalities  and  chronic  disease  among  the  pupils, 
followed  hy  the  institution  of  remedial  measures. 

CooPEiJATiox  IN  Scnooi.  Medical  Inspection 
Since  the  enactment  of  the  amended  Public  Health  Law  in 
1913,  and  of  the  amendments  to  the  Education  Law  relating  to 
the  physical  welfare  of  school  children  in  the  same  year,  there 
has  arisen  from  time  to  time  an  apparent  conflict  of  authority. 
So  many  questions  have  come  up  as  to  the  respective  duties  of  the 
health  officer  and  the  school  rhedical  inspector  that  it  was  thought 
advisable  to  define  as  closely  as  possible  the  duties  of  each  office 
and  to  point  out  the  methods  to  be  used  in  following  up  children 
absent  from  school  presumably  on  account  of  communicable  dis- 
ease. 

It  should  be  remembered  that  the  Education  Law  was  enacted 
subsequent  to  the  amendments  of  the  Public  Health  Law,  and  by 
imjjlication  amends  and  takes  the  place  of  paragraph  2  of  section 
21-b  of  the  Public  Health  Law.  This  law  i)rovides  that  a  school 
medical  inspector  shall  be  appointed  for  each  district  to  examine 
all  children  who  have  not  had  health  certificates  issued  after 
examination  by  their  family  physician.  Section  575  of  the  Edu- 
cation Law  "   ])rovides  that  pupils,  who  upon  investigation  show 


*  Section  575  of  the  Ediwatlon  Law:  "  Whenevt-r  uixm  investigation 
a  pupil  in  the  pul)lic  schools  shows  svniptonis  of  smallpox,  scarlet  fever, 
measles,  chickenpox,  tuberculosis,  diphtheria,  influenza,  tonsilitis,  whooping 
cough,  nuunps,  soal)ies  or  trachonui.  he  shall  be  excluded  from  the  school  and 
sent  to  his  home  immediately,  in  a  safe  and  i)roi)er  conveyance,  and  the 
health  officer  of  the  city  or  town  shall  be  inunedialely  notified  of  the  existence 
of  such  disease.  The  n"u'dical  inspector  shall  cxamii\c  each  pupil  returning  to 
a  school  without  a  certificate  from  the  health  otliccr  of  the  city  or  town,  or 
the  faniilv  physician,  after  absence  on  account  of  illness  or  from  iniknown 
cause.  Such  medical  inspector  may  niaJ<e  such  examinations  of  teachers, 
janitois  and  sciiool  buildin;.rs  us  in  their  opinion  the  health  of  the  pupils  and 
teachers  mav  require."     (Added  by  L.  l!)i:i,  ch.  027,  in  elTect  August  1.  1913.) 


Public  Health  Xuk.spxg  131 

symptoms  of  cert ;i in  comminiicable  diseases,   shall   be   excluded 
from  school  and  that  the  health  officer  shall  be  notified. 

Exclusion  From  School 

Children  shall  be  excluded  from  school  according  to  the  Public 
Health  Law  and  the  Sanitary  Code,  when  they  are  presumably 
affected  with  a  communicable  disease.  Teachers  throughout  the 
State  may  obtain  from  the  .State  Department,  of  Health  a  pam- 
phlet entitled,  "  Cooperation  in  the  Control  of  Communicable 
Diseases  Among  School  Children  "  which  will  be  of  great  value 
to  them  in  reporting  children  who  should  be  excluded  from  school. 
Children  may  be  excluded  by  the  principal  or  by  the  school  medi- 
cal inspector  or  the  health  officer.  When  a  child  is  excluded  from 
school  for  one  of  the  diseases  enumerated  in  either  Sanitary  Code 
or  Section  575  of  the  Education  Law,  the  child  should  be 
given  a  card  by  the  principal  or  teacher  notifying  the  parents 
that  the  child  was  sent  home  affected  with  symptoms  suggestive 
of  communicable  disease  and  the  local  health  officer  must  at  once 
be  notified.  In  order  to  return  to  school,  the  child  (in  accordance 
with  Section  575  of  the  Education  Law)  must  have  a  card  signed 
either  by  the  health  officer  or  school  medical  inspector,  or  if  by  the 
family  physician,  countersigned  by  either  one  of  these  officials 
(Regulation  26  of  Chapter  II  of  the  Sanitary  Code).  School 
authorities  should  remember  that  unless  such  cards  (supplied  by 
the  State  Department  of  Education)  are  provided,  and  unless  the 
child  or  its  parents  are  advised  as  to  the  conditions  on  which  the 
child  may  return  to  school,  the  latter  may  lose  much  school  time,  or 
the  parents  may  permit  the  child  to  return  to  school  while  still 
able  to  transmit  infection. 

Outbreaks  of  Communicable  Diseases 

Communicable  diseases  in  the  school  can  not  be  controlled  with- 
out efficient  work  and  hearty  cooperation  on  the  part  of  the 
local  health  and  school  officials,  the  family  physician  and  parents. 
The  school  medical  inspector  is  required  by  law  to  notify  the 
health  officer  of  every  case  of  communicable  disease  which  occurs 
in  a  school  child.    Conversely,  the  health  officer  should  report  to 


132  State  Depart^[ext  of  Health 

the  school  medical  inspector  every  case  of  communicable  disease 
which  occurs  in  a  family  in  which  there  are  children  of  school 
age.  What  is  ])erha])s  more  important  is  the  visiting  of  families  in 
which  c-hil(h'cn  are  a]jsent  irom  scliool.  Frequently  the  absence  is 
on  account  of  one  of  the  milder  communicable  diseases,  and  no 
physician  is  in  attendance  and  therefore  the  disease  has  not  been 
reported  to  the  health  officer.  For  this  reason  there  is  no  medical 
or  sanitary  supervision  of  the  case.  School  authorities  will  find 
it  of  extreme  value  to  have  a  school  nurse  or  attendance  officer  fol- 
low up  absentees  from  school,  and  in  this  way  will  frequently  dis- 
cover cases  of  communicable  disease.  Whenever  the  school  nurse 
or  attendance  officer  discovers  a  child  ill  with  a  disease  which  may 
1)0  communical)l(>  it  is  their  duty  to  report  promptly  all  the 
facts  to  the  local  health  officer.  It  is  not  the  health  officer's  duty  to 
visit  all  cases  of  sickness  unless  there  are  sufficiently  good  reasons 
to  believe  that  tlio  case  m;iy  be  one  of  conununicable  disease. 

It  will  be  found  of  great  advantage  to  the  school  nurse  or  attend- 
ance officer  to  keep  a  small  notebook  to  record  the  name,  age  and 
address  of  any  child  who  may  be  absent  from  school  on  account 
of  communicable  disease,  and  the  names  of  other  members  of  the 
family  attending  school.  The  school  medical  inspector  should  also 
keej)  a  record  of  communicable  disease  diagnosed  by  him  and 
reported  to  the  local  health  authorities. 

On  the  other  hand,  the  health  officer  should  not  only  investigate 
and  visit  or  cause  to  be  visited  every  household  where  a  case  of 
comnuinicable  disease  is  reported  or  suspected  to  be  present,  but 
also  should  make  a  list  of  the  names  of  all  the  persons  who  live  in 
the  house  and  this  list  shoidd  be  kept  and  the  house  revisited  from 
time  to  time  in  order  to  ascertain  whether  or  not  quarantine  is 
being  observed  in  the  infected  liousehold  or  whether  any  of  the 
contacts  have  "come  down"  with  the  disease.  If  communicable 
disease  exists  in  epidemic  form  in  any  community,  it  is  generally 
wiser  not  to  close  the  school  but  to  keep  the  various  classes  under 
da'iy  siipei'vision  and  to  exclude  promptly  jx-rsons  suspected  of 
develoi)ing  the  diac^ase.  It  will  usually  be  found  preferable  to 
exclude  a  certain  class  or  classes  from  school  rather  than  to  close 


Public  Health  NuRsrA^G  133 

the  entire  school.  Whenever  an  outbreak  occurs,  it  is  recom- 
mended that  the  school  medical  inspector  make  daily  visits  to  the 
school  if  daily  inspection  is  not  made  and  inspect  all  the  children, 
and  the  health  officer  will  be  expected  to  cooperate  with  him  and 
render  all  assistance  possible,  but  it  is  believed  that  it  is  the  pri- 
maiy  duty  of  the  school  inspector  assisted  by  the  school  nurse,  if 
one  is  employed,  to  perform  this  service. 

Before  making  examinations  of  children,  whether  for  an  ordi- 
nary physical  examination  or  for  the  presence  of  a  communicable 
disease,  the  usual  aseptic  precautions  should  be  taken.  For 
examining  the  throat  an  ample  supply  of  wooden  tongue  depres- 
sors should  be  provided,  also  facilities  for  disinfecting  thermo- 
meters. Physicians  and  nurses  should  use  extreme  care  that  the 
hands  are  thoroughly  washed  before  and  after  each  examination 
of   the   nose    and   throat. 

At  the  close  of  an  epidemic  terminal  fumigation  is  not  always 
necessary,  but  the  school  room  or  rooms  where  cases  of  communi- 
cable disease  have  been  detected  should  be  scrubbed  with  soap  and 
hot  water  and  then  given  a  thorough  airing.  During  the  exist- 
ence of  an  epidemic  it  is  of  great  advantage  to  have  w^^niings 
issued  in  the  press  and  also  in  the  form  of  bulletins  in  which  refer- 
ence is  made  to  the  fact  that  the  Public  Health  Law  requires  heads 
of  families  to  report  to  the  health  officer  suspected  cases  of  com- 
municable disease  coming  to  their  notice  if  no  physician  is  in 
attendance  (Reg.  5,  Chapter  II  Sanitary  Code.) 

The  ]^ew  York  State  Education  Law  provides  for  the  medical 
inspection  of  all  pupils  attending  the  public  schools  in  the  State. 
It  states  that  medical  inspection  shall  not  only  include  the 
examination  of  school  children  for  physical  defects  but  shall  also 
provide  for  the  exclusion  from  school  of  all  pupils  who  show 
symptoms  of  smallpox,  scarlet  fever,  measles,  chickenpox,  tuber- 
culosis, diphtheria,  influenza,  tonsilitis,  whooping  cough,  mumps, 
scabies  or  trachoma.  Although  the  law  is  quite  specific  on  many 
points,  it  does  not,  in  this  section,  definitely  state  how  these  diag- 
noses shall  be  made  or  how  pupils  shall  be  excluded  from  school. 
It   does  provide,  however,  that  upon  returning  to  school   after 


134  State  Departmknt  of  Health 

al)seiK*e  on  account  of  illness  from  unknown  cause,  each  pupil 
shall  he  examined  by  the  medical  inspector  unless  he  has  a  cer- 
tificate from  the  health  officer  of  the  city  or  town,  or  from  the 
family  physician,  and  reji:ulation  20  of  chapter  II  of  the  Sani- 
tary Code,  already  quoted,  furthermore  requires  that  if  such  cer- 
tificate is  signed  by  the  attending  physician  it  should  be  counter- 
signed by  the  health  officer  or  school  medical  inspector.  The 
communicable  diseases  mentioned  in  the  law  occur  more  frequently 
among  children  of  school  age  than  in  any  other  age  group,  and 
every  effort  should  he  made  to  prevent  the  spread  of  communicable 
disease  among  such  children. 

The  law  further  provides  that  the  Commissioner  of  Education 
may  adopt  rules  and  regulations,  not  inconsistent  with  the  ]u-o- 
visions  of  the  section  of  the  law,  for  the  purpose  of  carrying  into 
lull  force  and  effect  the  objects  of  the  law. 

There  is  no  question  but  that  teachers  *  should  he  taught  the 
beginning  symptoms  of  communical)le  diseases,  that  children 
should  be  excluded  from  school  who  have  evidence  of  such  dis- 
eases, and  that  such  children  should  not  be  allowed  to  return  to 
school  except  on  certificate  of  the  physician  countersigned  by 
either  the  school  medical  inspector  or  the  health  officer. 

Juvenile  Health  Officers  for  School  I\ooms 

The  appointment  of  a  "  Juvenile  Health  Officer "  in  each 
school  room  —  appointments  1o  he  made  by  the  teacher  at  inter- 
vals and  a])pointoes  to  include  both  boys  and  girls  —  will  stimulate 
interest,  have  an  educational  infiuence,  and  may  furnish  the 
teacher,  nurse,  or  medical  inspector  with  valuable  information. 
The  Juvenile  Health  Officer  should  be  dejnitized  to  submit  to 
the  teacher  any  information  in  regard  to  chiblren  out  of  school 
on  account  of  illness  who  mav  be  suft'eriuiz;  from  a  communicable 


*  The  State  Doi.artmont  of  Education  is  (lovclopint:  a  system  tlii(iu,i:li  wli 
tills  instruct  ion  will  lie  ''iven  to  teachers. 


PuBi.ic  Heai/i'ii  XuRsrxc. 


135 


disease.     A  coiiveiii(>iit  form  for  such  a  report,  shown  bclov;,  wil 
be  popuhir  with  the  juvenile  official. 


DIST.  NO 

WEEK  ENDING 


Juvenile  Healtji  Officer's  Report 
GRADE 


19. 


3 


Number  of  pupils  enrolled 

Number  absent  because  of  illness 

Number  absent  because  of  typhoid  fever . 

diphtheria 

smallpox 

chickenpox 

scarlet  fever  (scarlatina).. 

whooping  cough 

mumps 

measles 

pinkeye, 

Other  diseases  (write  names  of 


Other  absentees  (cause  of  absence  given) 


Day  of  Week 


M    T    W     T     F 


Javena3  Health  Officer. 


In  order  properly  to  control  outbreaks  of  communicable  dis- 
eases, and  in  order  to  prevent  the  occurrence  of  cases  of  such 
diseases  in  the  public  schools,  a  series  of  regulations  have  been 
drawn  up  }\v  the  State  Commissioners  of  Health  and  of  Education, 
in  accordance  with  the  provisions  of  the  Educational  L;nv, 
definitely  defining  the  duties  of  tlie  school  medical  inspector, 
principal,  teacher,  and  local  health  officer,  as  follows: 

Rules  and  Regulations  for  Health  Officers  and  School 

Medical  Inspectors  for  the  Control  of  Communicable 

Disease 

1  Whenever  a  school  teacher,  a  school  medical  inspector,  school 
nurse,  or  attendance  officer  discovers  that  any  school  child  absent 
from  school  is  affected  with  any  disease  presumably  communicable, 
he  or  she  shall  report  forthwith  to  the  local  health  officer  all 


136  State  DEPAKT:\rENT  of  Health 

known  facts  relating  to  the  illness  of  the  child,  together  with  the 
name,  age,  address,  school  attended  tmd  gi-ade  of  such  child  and 
the  name  of  the  physiciiai,  if  any,  in  attendance. 

2  When  no  physician  is  in  attendance,  it  shall  be  the  duty  of  the 
local  health  officer  to  investigate  the  nature  of  the  illness  of  every 
person  within  his  jurisdiction  reported  to  him  as  affected  with  a 
disease  presumably  communicable. 

3  Whenever  a  case  of  communicable  disease  occurs  in  any  school, 
it  shall  be  the  duty  of  the  school  medical  inspector  to  notify  the 
health  officer  of  such  case  immediately  and  to  ask  his  cooperation 
and  assistance  in  controlling  the  disease  in  said  school. 

4  Whenever  a  case  of  communicable  disease  occurs  in  any 
school  in  his  jurisdiction  it  shall  be  the  duty  of  the  health  officer 
to  render  every  assistance  possible  to  the  school  medical  inspector 
in  the  control  of  said  disease. 

5  Whenever  a  case  of  communicable  disease  occurs  in  any 
school,  and  there  is  no  school  medical  inspector  directly  responsible 
for  the  prevention  and  control  of  communicable  disease  in  said 
school,  it  shall  be  the  duty  of  the  local  health  officer  to  take  all 
steps  necessary  to  prevent  the  spread  of  the  disease. 

6  Whenever  a  child  in  attendance  at  school  is  reported  to  the 
school  medical  inspector  ])y  the  school  nurse  or  teacher  as  being 
affected  with  a  disease  presumably  communicable,  it  shall  be  the 
duty  of  the  school  medical  inspector  to  examine  the  child  promptly, 
and  if  such  child  is  affected  with  a  communicable  disease  the 
school  medical  inspector  shall  report  immediately  to  the  local 
health  officer  all  the  facts  relating  to  the  illness,  together  with  the 
name  and  address  of  such  child. 

7  Whenever  a  case  of  communicable  disease  in  a  family  with 
a  child  or  children  of  school  age  is  reported  to  the  local  health 
officer,  it  shall  be  the  duty  of  the  local  health  officer  to  notify  the 
school  medical  inspector  ])romptly  of  the  name,  age,  schotd 
attended,  grade  and  address  of  sucli  cliild  ov  children  and  the 
nature  of  the  coiniinuiicnble  disease,  and  also  of  the  names,  ages, 
schools  atleiided  ;iiid  grades  of  all  oilier  children  in  the  same 
household. 


Public  Health  Nursi-xg  137 

If  these  rules  and  regulations  could  be  fully  understood  and 
put  in  force  by  the  local  authorities,  a  very  long  step  would  be 
taken  in  the  control  of  communicable  diseases  in  schools. 

In  far  too  many  of  our  smaller  cities  and  in  our  villages  and 
towns,  there  is  a  desire  on  the  part  of  the  school  trustees  to  close 
a  school  whenever  there  is  an  outbreak  of  a  communicable  disease. 
The  Education  Law  does  not  cover  this  situation  and  the  trustees 
undoubtedly  have  the  authority  to  take  this  action.  Here  is 
where  tact  and  cooperation  are  necessaiy,  for  the  school  trustees 
may  in  their  right  do  as  they  choose,  but  if  properly  approached, 
and  if  the  situation  is  properly  presented  to  them,  they  will  do 
the  wise  thing  and  provide  for  the  proper  following  up  of  each 
absentee  from  school,  and  see  that  the  cases  are  controlled  out- 
side of  the  schools,  and  that  cases  of  suspected  illness  are  excluded 
promptly. 


ms 


Statk  Depai;t.m 


Hi 


CHAPTER    X 

The   Public    Health   Laboratory 

The  public  health  laborator}^  is  an  institution  the  initiation 
and  development  of  which  has  occurred  within  the  memor\'  of 
sonic  of  the  readers  of  this  ni;inual,  l)Ut  it  is  to-da_v  generally 
i^egarded  as  a  most  important  and  essential  feature  of  public 
health  work.  The  following  diagram,  showing  the  number  of 
diagnostic  specimens  (in  diphtheria,  tuberculosis,  typhoid,  syphi- 
lis, and  other  diseases)  examined  in  the  New  York  State  Labora- 
tory aniuially  since  1913,  indicates  gTaphically  the  extent  of 
increase  in  demand  for  this  branch  of  laboratory  service. 


Total  Number  of  Diagnostic  Examinations  of  Diphtheria,  Tuber- 
culosis, Typhoid  Fevsr,  Syphilis  and  other  Diseases 


^ 

L 

8i7. 

•■^ 

r^ 

Public  Health  NuRsrxo  139 

The  New  York  State  Laboratory,  located  at  Albany,  is  in 
charge  of  the  Director  of  the  Division  of  Laboratories  and  Ke- 
search  of  the  State  Department  of  Health.  Generally  speaking,  its 
most  important  functions  are  the  examination  of  diagnostic  speci- 
mens from  cases  of  communicable  disease ;  the  analysis  of  samples 
of  water  from  public  water  supplies;  the  preparation  and  distri- 
bution of  antitoxins,  serums,  vaccines  and  chemical  preparations 
used  for  the  prevention  and  treatment  of  communicable  disease, 
as  well  as  culture  media  and  outfits  for  the  collection  of  speci- 
mens for  examination;  and  research  directed  toward  improve- 
ment of  old  and  the  development  of  new  methods  of  procedure  for 
the  prevention  and  treatment  of  disease. 

Because  in  many  instances  prompt  reporting  upon  examination 
of  diagnostic  specimens  is  of  great  importance  and  transportation 
of  such  specimens  necessarily  consumes  time  and  involves  other 
difficulties,  many  counties  and  other  municipalities  have  estab- 
lished local  laboratories  in  which  such  specimens  are  examined. 
Bacteriological  tests  upon  milk  samples,  the  nature  of  which 
makes  transportation  for  considerable  distances  impracticable,  are 
usually  also  made  at  local  laboratories. 

It  is  not  essential  that  the  public  health  nurse  be  intimately 
aet[uainted  with  the  details  of  laboratory  procedures.  She  should, 
however,  be  familiar  with  the  functions  of  the  laboratory  and  she 
should  know  what  specimens  will  be  accepted  for  examination 
and  under  what  conditions,  and  how  to  prepare  them. 

In  most  instances  when  preparing  laboratory  specimens  she  will 
be  working  under  the  supervision  of  a  health  officer  or  other 
physician,  who  will  also  assume  responsibility  for  interpreting 
reports ;  but  it  will  often  prove  a  decided  advantage  if  the  nurse 
has  sufficient  general  knowledge  to  enable  her  also  to  interpret 
Iriboratory  reports  intelligently.  In  the  following  chapter  those 
diseases  in  which  laboratory  examinations  are  of  such  value  that 
])hysicians  require  them  constantly  are  briefly  discussed  and  the 
purposes  of  such  examinations  are  explained. 


140  State  Depaetaient  of  Health 


CHAPTER    XI 
Laboratory  Service 

Genekal  Considerations 

Laboratory  supplies  furnished  by  the  State,  including  anti- 
toxins and  other  products  for  prevention  and  treatment,  and  diph- 
theria culture  tubes  and  outfits  for  collecting  laboratory  speci- 
mens, are  distributed  through  local  supply  stations  maintained 
either  by  health  officers  or  under  their  supervision.  Physicians 
and  nurses  secure  their  supplies  from  such  stations,  except  where 
they  are  issued  through  local  laboratories. 

Health  officers  receiving  supplies  for  distribution  obligate  them- 
selves to  keep  them  under  proper  conditions,  to  exchange  those 
which  are  perishable  as  often  as  necessary,  and  to  make  them 
easily  accessible  to  those  having  occasion  to  use  them. 

Packages  containing  antitoxins  and  other  perishable  products 
for  immunization  or  treatment  have  noted  upon  them  the  dates  of 
preparation  or  testing.  The  time  after  which  the  product  should 
not  be  used  is  recorded  either  on  the  label  or  on  the  circular  en- 
closed in  each  package.  The  packages  should  be  kept  constantly 
in  a  cold  dark  place,  preferably  in  an  ice  chest.  If  kept  under 
such  conditions,  they  will  retain  their  strength  for  the  periods 
indicated  by  the  expiration  dates.  Diphtheria  culture  tubes  con- 
tain "  slants  "  of  grayish  white  culture  medium  (coagulated  blood 
serum),  wliicli  sliould  present  a  smooth,  moist  surface.  Products 
of  expired  date  or  culture  tubes  containing  media  which  has  dried 
and  separated  from  the  sides  of  the  tubes  should  never  be  accepted 
for  use. 

Health  officers  are  supplied  with  containers  for  various  speci- 
mens to  be  transmitted  to  the  laboratory,  including  material  for 
cultures,  specimens  of  blood,  fecal  and  urinary  discharges, 
sputum,  pus,  etc.  These  are  so  equipped  for  mailing  as  to  com- 
ply with  postal  I'egnlations  and  should  invariably  be  used  in 
accordance  with  directions  accompanying  them. 

Accoin])ii]iyiiig  ea<^li  specimen  ''  <mtfit,"  is  a  blank  information 
form  to  be  filled  out  and  returned  with  the  specimen.     Infoi*ma- 


Public  Health  IS^ursi-ng  141 

tioii  asked  for  is  either  required  by  law  or  for  the  guidance  of 
laboratory  workers  in  making  examinations  of  specimens  and 
interpreting  results,  and  should  always  be  given  as  fully  as  pos- 
sible. The  public  health  nurse  will  frequently  have  occasion 
either  to  prepare  specimens  for  mailing  or  to  fill  out  information 
blanks  for  specimens  prepared  by  the  health  officer  or  attending 
physician.  She  should  bear  in  mind  the  fact  that  failure  to  fur- 
nish information  asked  for  may  not  only  cause  serious  incon- 
venience, but  may  also  be  responsible  for  delay  in  the  return  of  a 
report.  In  view  of  the  very  large  number  of  specimens  examined 
daily  in  the  State  Laboratory  the  work  necessarily  becomes 
routine;  if  complete  data  is  submitted  with  specimens,  attention 
will  be  called  in  special  instances  to  the  advisability  of  devoting 
more  than  the  ordinary  amount  of  time  to  the  examination  of  a 
specimen  or  of  submitting  it  to  special  tests. 

Communicable  Diseases, 

j^ Diphtheria.  Infectious  agent;  the  diphtheria  bacillus  (some- 
times called  "  Klebs-Loeffler  "  bacillus) .  In  typical  cases  a  gray- 
ish white  false  membrane  forms  in  the  throat,  nose,  or  larynx. 

Except  in  the  most  typical  oases,  positive  diagnosis  of  diph- 
theria is  difficult  or  impossible  without  resort  to  laboratory  aids. 
False  membrane  may  be  present  in  Vincent's  angina,  septic  sore 
throat  and  other  conditions,  as  well  as  in  diphtheria.  On  the  other 
hand  in  many  cases  of  true  diphtheria  from  which  virulent  diph- 
theria bacilli  may  be  conveyed  to  others  no  membrane  can  be 
seen.  Such  cases,  simulating  tonsilitis  or  ordinary  sore  throat, 
are  especially  dangerous  because  likely  to  be  overlooked.  They 
can  be  diagnosed  only  by  discovering  the  presence  of  the  diph- 
theria bacilli.  For  this  reason  the  State  Sanitary  Code  provides 
that  every  physician  attending  a  case  in  which  there  is  reason  to 
suspect  the  existence  of  diphtheria  shall  take  a  culture,  and  sub- 
mit it  to  an  approved  laboratory  for  examination. 

The  Sanitary  Code  also  requires  that  cases  of  diphtheria,  before 
being  released  from  quarantine,  shall  have  two  successive  cultures 
from  the  nose  and  throat,  taken  not  less  than  24  hours  apart, 
neither  of  which  shall  show  the  presence  of  diphtheria  bacilli,  the 
iirst  en  1  lure  to  be  taken  not  less  than  9  davs  from  the  date  of  on^et 


112  State  Dei'Aktmfxt  of  HEAr/rii 

of  the  disease.  This  mle  does  not  constitute  an  absolute  safe- 
guard, since  sunic  who  are  released  even  after  two  successive 
negative  cultures,  still  harbor  a  few  diphtheria  bacilli,  usually  for 
a  short  time.  It  is  one  very  generally  ado])ted,  however,  and 
experience  has  demonstrated  that,  as  a  practical  measure,  its 
efficient  application  produces  satisfactoiy  results. 

In  nearly  all  of  the  larger  communities  cultures  for  release  of 
diphtheria  cases  are  now  taken  by  the  health  officer  or  his  official 
representative.  This  is  desirable,  both  from  the  standpoint  of  the 
Health  Department  and  the  attending-  physician.  The  ])ulilic 
health  nurse  is  most  likely  to  be  the  "  official  representative  "  to 
whom  the  duty  of  taking  material  for  release  cultures  will  be  as- 
signed. She  may  also  be  called  upon  to  take  material  for  cultures 
from  suspected  cases.  She  should,  therefore,  be  familiar  with  the 
procedure,  (see  Laboratory  Manual)  and  acquire  proficiency  by 
practice. 

It  is  sometimes  possible  to  make  a  laboratory  diagnosis 
of  diphtheria  by  examination  of  a  ''  smear "  made  directly 
from  the  swab  used  in  taking  material  for  culture.  Such 
a  "smear"  is  prepared  by  rubbing  the  swal)  (after  swabbing 
the  throat)  over  the  surface  of  a  glass  microscopical  slide  (mis- 
cellaneous outfit  in  lilac  envelope)  until  it  is  apparent  that  some 
of  the  material  from  the  throat  has  been  transferred  to  the  slide, 
after  which  s]>ecimens  should  be  allowed  to  dry  pre])aratory  to 
fixing  by  heat  and  staining.  Laboratory  practice,  however, 
requires  that  this  preliminary  diagnosis  be  confirmed  by  exami- 
nation of  material  from  a  culture.  This  is  especially  important 
when  examination  of  the  smear  has  failed  to  reveal  the  ])resence 
of  diphtheria  bacilli. 

If  Vincent's  angina  is  suspected  a  smear  should  be  sulnnitted. 
It  is  necessary,  however,  to  use  the  swab  more  vigorously  and  Avith 
more  pressure  than  in  securing  material  for  cultures.  When 
special  examinations  or  tests  are  required,  this  should  be  clearly 
indicated  upon  the  information  l>lanks  accompanying  the 
specimens. 

It  is  now  well  known  that  there  is  only  one  effective  method  of 
treatment  f(tr  cas(>s  of  <lii)htheria  and  that  this  is  specific  ^ — 
the  administration  of  diphtheria  antitoxin.  When  the  toxin 
formed  by  diphtheria  bacilli  gets  into  the  circulation,  it  enters  into 


Public  Health  XuRsi-xa  143 

chemical  coiiil)ination  with  body  tissue,  thereby  injuring  or  do- 
stroying  tissue  cells.  The  ultimate  result  of  injury  to  nerve  tis- 
sues, which  are  especially  susceptible  to  the  effect  of  the  toxin,  is 
sometimes  a  so-called  "  post-diphtheritic  "  paralysis  or  even  sud- 
den death.  Diphtheria  antitoxin  readily  combines  with  free  toxin 
and  so  prevents  it  from  combining  with  body  tissues.  If  the 
toxin  has  already  entered  into  combination  with  body  tissue,  anti- 
toxin is  no  longer  of  value,  except  for  its  effect  upon  toxin  subse- 
quently formed.  For  this  reason  antitoxin  becomes  less  effective 
with  each  day's  delay  in  administration.  When  an  early  and 
liberal  dose  is  given  the  antitoxin  combines  with  any  toxin  already 
discharged  from  the  bacilli  and  renders  it  harmless  and  surplus 
antitoxin  circulates  in  the  blood  for  several  days,  free  to  combine 
with  toxin  that  may  subsequently  be  formed.  In  such  cases 
prompt  recovery  is  likely  to  occur  after  a  single  adequate  dose. 

Antitoxin  is  also  administered  to  persons  who  have  been 
exposed  to  diphtheria  and  who  are  believed  to  be  susceptible,  for 
the  purpose  of  producing  immunity  (a  specific  insusceptibility) 
to  diphtheria  infection.  The  immunity  thus  established  is  tem- 
porary, generally  lasting  from  two  to  three  weeks.  This  is  usually 
adequate  if  the  individual  is  immediately  removed  from  further 
exposure. 

Much  more  lasting  imnmnity  against  diphtheria  may  be  pro- 
duced by  administration  of  standard  "toxin-antitoxin  mixture."' 
(See  Laboratory  Manual.)  This  procedure,  however,  may  con- 
sume several  weeks  and  is  not  ada])ted  for  use  in  emergencies. 
Treatment  with  toxin-antitoxin  mixture  has  been  introduced 
too  recently  for  it  to  be  possible  to  know  how  long  the  immunity 
will  last.  There  seems  (o  be  little  doubt,  however,  that  an  active 
immunity  persists  for  at  lea.-^t  three  years  and  ])robably  for  a  con- 
siderably longer  period,  if  not  permanently.  Injections  of  diph- 
theria antitoxin  —  which  give  protection  for  two  or  three  weeks  — 
must,  therefore,  always  be  used  where  exposure  has  occurred  and 
immediate  protection  is  necessary. 

Many  individuals  possess  a  natural  or  acquired  immunity  to 
diphtheritic  infection,  and  therefore  do  not  require  artificial 
immunization.  By  the  ''  Schick  test  "  one  can  determine  whether 
or  not  immunity  already  exists.     (See  Laboratory  Manual.)     A 


1  1:4  State  Department  of  Health 

minute  and  definite  quantity  (0.1  c.  c. )  of  a  standard  solution  of 
diphtheria  toxin  is  injected  into  the  skin  of  the  forearm.  In  per- 
sons who  are  susceptible  a  bright  red  reaction  develops  within  24 
to  72  hours.  This  test  is  particularly  adapted  to  use  in  institutions 
or  where  large  numbers  of  persons  are  involved  and  should  only  be 
attempted  by  physicians  familiar  with  its  use.  Diphtheria  toxin 
is  one  of  the  most  powerful  poisons  known.  Serious  and  even  fatal 
results  may  follow  its  use  in  connection  with  the  Schick  test  in 
inexperienced  hands. 

Persons  who  have  recovered  from  diphtheria  may  continue  to 
carry  diphtheria  bacilli  in  their  throats  or  noses  for  varying 
lengths  of  time.  Again,  those  who  are  themselves  immune  may 
acquire  and  harbor  the  organisms,  being  a  source  of  danger  to 
others,  though  they  themselves  do  not  become  ill.  Such  indi- 
viduals are  known  as  diphtheria  "  carriers."  The  public  health 
nurse  may  be  called  upon  to  take  material  for  cultures  for  the 
detection  or  release  of  such  carriers,  who  are  subject  to  special 
rules  and  regulations.  (See  Manual  on  The  Prevention  and  Con- 
trol of  Communicable  Diseases,  page  136.) 

The  nurse  who  regularly  comes  in  contact  with  diphtheria  cases 
or  carriers  should  not  overlook  the  possibility  that  she  may 
acquire  the  disease,  or  become  a  carrier,  and  thus  unwittingly  con- 
vey the  infectious  agent  to  others — especially  to  children.  If 
there  is  doubt  as  to  her  immunity  the  qiiestion  should  be  settled 
by  means  of  a  "  Schick  test."  If  she  is  found  to  be  susceptible, 
much  more  lasting  and  possibly  permanent  immunity  may  be 
produced  through  the  administration  of  toxin-antitoxin  mixture. 
Before  leaving  a  case  she  should  invariably  wash  her  hands  thor- 
oughly with  soap  and  water.  Every  reasonable  precaution  should 
be  observed  to  avoid  contact  with  or  transference  of  infected 
secretions. 

Tuberculosis.  1  niVcticus  agent:  tlic  tubercle  IjaciHus.  One  of 
the  duties  of  the  public  health  mirse  may  l)e  to  collect  specimens 
of  sputum  from  cases  of  suspected  pulmonary  tuberculosis.  (For 
directions  see  Laboratory  Maiiuul.  )  ThImtcI)^  bncilli  are  usually 
present  in  the  sputum  in  cases  in  wliicli  llioc  is  n  brokiMi-down 
tubci'culous  lesion  dischargiii!;  into  llie  :iir  passages.  A  minute 
lesion  may  discharge  bacilli  for  a  time  and  ultimately  heal.  When 


Public  Health  ISTuRsnYG  145 

tubercle  bacilli  are  found  regularly  and  in  large  numbers,  it  indi- 
cates that  the  disease  has  passed  the  incipient  stage. 

Failure  to  find  tubercle  bacilli  in  one  or  more  specimens  of 
sputum  does  not  indicate  that  the  patient  is  not  suffering  from 
tuberculosis.  There  may  at  the  time  be  no  discharging  lesion  or 
the  various  specimens  may  not  have  included  material  from  the 
infected  portion  of  the  lung.  Furthermore,  when  only  a  few 
organisms  are  present,  they  may  be  overlooked,  even  after  pro- 
longed search.  In  suspected  cases,  when  negative  reports  are 
received,  further  specimens  shoidd  always  be  submitted  for 
examination. 
'^l-  Typhoid  fever.  Infectious  agent ;  the  typhoid  bacillus.  After 
about  the  second  week  of  illness  in  a  case  of  typhoid  fever  the 
bacilli  usually  begin  to  appear  in  the  intestinal  discharges  and 
frequently  in  the  urine.  As  a  rule  the  organisms  disappear  within 
a  short  time  after  recovery  from  the  disease.  "When  they  persist, 
as  they  sometimes  do,  the  individual  is  regarded  as  a  typhoid 
"  earrier."  The  typhoid  carrier,  unless  discovered  and  kept  under 
observation,  may  be  a  greater  source  of  danger  than  a  person  ill 
with  the  disease,  since  the  activities  of  the  latter  are  lim.ited  as  a 
result  of  his  illness. 

Carriers  are  detected  through  laboratory  examinations  of  speci- 
mens of  fecal  and  urinary  discharges.  When  discovered  they 
are  subject  to  special  rules  and  regulations.  (See  Manual  on  The 
Prevention  and  Control  of  Communicable  Diseases,  page  140.) 

Except  in  typical  cases,  the  diagnosis  of  cases  of  typhoid  fever 
is  difficult  or  impossible  without  resort  to  laboratory  tests.  The 
simplest  of  these  is  the  "  agglutination  "  test  (Widal),  made  with 
specimens  of  blood  from  the  suspected  cases.  (See  Laboratory 
Manual.)  After  about  the  tenth  day  of  the  illness,  the  blood 
serum  (the  clear  fluid  which  separates  from  the  blood  in  the  pro- 
cess of  clotting)  of  a  typhoid  case,  when  mixed  in  proper  dilution 
with  typhoid  bacilli  grown  upon  culture  medium  in  the  labora- 
tory, will  cause  the  bacilli  to  form  in  clumps  or  ''  agglutinate." 
The  Sanitary  Code  requires  every  physician  attending  a  case  of 
illness  in  which  there  is  reason  to  susj)ect  typlioid  (or  para- 
typhoid) fever,  to  take  blood  specimens  to  be  submitted  for  exami- 
nation by  an  approved  laboratory. 


146  State  I)EPART^rKNT  of  Health 

Immunity  against  typhoid  fever  may  be  established  for  a  vary- 
ing period  of  from  one  to  four  or  more  years,  by  the  administra- 
tion of  typhoid  vaccine,  consisting  of  dead  tj^hoid  bacilli.  (See 
Laboratory  Manual.) 

Paratyphoid  fever.  Infectious  agent;  the  paratyphoid  bacillus, 
closely  related  to  the  typhoid  bacillus.  The  disease  frequently 
resembles  typhoid  fever,  but  is  of  shorter  duration.  Blood  from 
a  paratyphoid  case  usually  agglutinates  paratyphoid  bacilli,  by 
which  the  diagnosis  may  be  determined.  The  agglutination  test 
is  less  reliable  than  that  in  typhoid  fever.  Paratyphoid  bacilli 
may  sometimes  be  demonstrated  in  fecal  specimens,  while  the 
agglutination  reaction  is  still  absent.  When  there  is  a  question 
as  to  whether  a  case  is  one  of  typhoid  or  paratyphoid  fever,  both 
typhoid  and  paratyphoid  tests  will  be  made  on  the  same  blood 
or  fecal  specimen  upon  request. 

Immunity  is  established  by  administration  of  vaccine  contain- 
ing dead  paratyphoid  bacilli.  It  is  customary  to  immunize  at  the 
same  time  against  typhoid  and  paratyphoid  by  use  of  mixed 
vaccines. 

Dysentery.  There  are  two  varieties  of  dysentery,  a  disease  of 
the  intestinal  tract;  one  incited  by  a,  microorganism  kno\\m  as  the 
amceha  coll,  and  prevailing  chiefly  in  tropical  and  subtropical 
countries,  the  other,  not  uncommon  in  ^ew  York  State,  incited 
by  the  dysentery  bacillus. 

The  diagnosis  of  bacillary  dysentery  may  be  determined  or 
confiiTiied  by  a  blood  agglutination  test  similar  to  that  used  to 
diagnose  typhoid  fever  or  by  demonstration  of  the  bacilli  in  fecal 
specimens.  The  latter,  in  this  disease,  is  the  more  practical  and 
reliable  method. 

Persons  who  have  recovered  from  dysentery  may  continue  to 
discharge  the  infectious  agent,  as  in  typhoid  fever,  and  unless  the 
carrier  condition  is  discovered  may  convey  the  infective  agent  to 
others. 

Tetanus  {"  lock-jaw  ").  Infectious  agent;  the  tetanus  bacillus. 
The  bacillus  is  frequently  present  in  road  dirt  and  garden  soil  con- 
taining stable  manure  and  grows  readily  in  (ltM>])  wounds  from 
which  air  is  excluded.  Penetrating  wounds  an<l  those  which  are 
badly  lacerated  and  contaminated  are  most  favorable  for  the 
development  of  tetanus.     Tetanus  antitoxin,  administered  at  the 


Public  Health  Xursing  147 

time  of  receiving  such  an  injiirv,  with  appropriate  surgical  treat- 
ment of  the  wound,  is  usually  effective  as  a  preventive  of  tetanus. 
Tetanus  antitoxin  is  far  less  effective  in  the  treatment  of 
tetanus  than  in  its  prevention.  Successful  results,  however,  have 
followed  the  administration  of  large  doses,  even  after  symptoms 
of  the  disease  have  made  their  appearance.  The  toxin  discharged 
by  tetanus  bacilli  is  a  very  powerful  poison.  It  enters  into 
chemical  combination  with  body  tissue  even  more  read'ly  than 
does  diphtheria  toxin  and  has  a  special  affinity  for  the  cells  of  the 
central  nervous  system  (brain  and  spinal  cord).  Tetanus  anti- 
toxin coinbines  with  some  of  the  free  toxin  and  thus  prevents  it 
from  combining  with  and  injuring  the  tissue  cells.  Results  are 
apt  to  be  less  successful  than  in  the  treatment  of  diphtheria  with 
diphtheria  antitoxin  for  two  reasons:  (1)  By  the  time  the  first 
symptoms  appear  the  disease  is  already  well  advanced  and  all  that 
can  be  reasonably  expected  of  the  treatment  is  the  prevention  of 
absorption  of  further  amounts  of  active  toxin  by  the  nervous  sys- 
tem, and  (2)  owing  to  its  method'  of  transmission  (along  the 
axis  cylinders  of  nerves)  it  is  less  easily  reached  by  the  antitoxin 
in  the  circulating  fluids.  The  best  results  have  followed  injection 
of  large  doses  of  antitoxin  intraspinally  and  intravenously  (into 
the  spinal  canal  h\  hunliar  puncture  and  into  a  vein  at  the  time 
of  appearance  of  the  first  symptoms). 

Pertussis  {"  ivliooping  cough"').  Infectious  agent;  probably 
the  pertussis  bacillus  (although  this  has  not  been  established 
beyond  question)  ;  present  in  discharges  from  the  nose  and  throat 
of  cases.  The  laboratory  prepares  a  vaccine,  consisting  of  killed 
pertussis  bacilli,  which  has  been  used  both  for  prevention  and 
treatment.  While  its  value  has  not  yet  been  satisfactorily  estab- 
lished, severe  reactions  rarely  follow  its  administration  and  a 
number  of  observers  have  reported  satisfaetoiy  results  from  its 
use.     (See  Laboratory  Manual.) 

Malaria.  Infectious  agent;  a  plasmodium,  present  in  the  blood 
of  infected  persons.  The  plasmodium  is  transferred  from  one 
individual  to  another  only  by  the  bite  of  the  female  anopheles 
m()S(iuito  and  its  dissemination  depends  upon  the  presence  of  this 
mosquito.  Diagnosis  is  made  or  confinned  by  finding  the  plas- 
znodium  in  blood  specimens.      (See  Laboratory  Manual.  )      On 


148  State  Depaktmknt  of  Health 

account  of  the  similai-ity  of  the  symptoms  of  malaria  and  typhoid 
fever,  a  laboratory  test  of  the  blood  of  the  patient  should  be  made 
wherever  there  is  a.  (|uestion  of  diagnosis. 

Epidemic  cerehrospinal  meningitis.  Infectious  agent ;  the 
meningococcus.  Other  forms  of  meningitis  are  incited  by  other 
organisms  or  occur  as  a  complication  of  other  diseases.  The 
diagnosis  is  often  difficult  or  impossible  without  resort  to  labora- 
tory aids.  The  common  procedure  is  for  the  attending  or  consult- 
ing physician  to  make  a  lumbar  (spinal)  puncture,  withdrawing 
spinal  fluid,  which  is  used  for  bacteriological  examination  and 
replaced  by  antimeningococus  serum  if  the  fluid  withdrawn  is 
found  to  be  cloudy.     (See  Laboratory  Manual.) 

The  infective  agent  occurs  in  the  discharges  from  the  noses  and 
throats  of  cases  and  carriers.  The  culturing  of  meningitis  cases 
and  carriers  requires  special  apparatus  and  methods  and  is 
impracticable  except  in  the  hands  of  those  familiar  with  the 
technique  and  when  cultures  can  be  taken  directly  to  the 
laboratory. 

Pneumonia.  Infectious  agent  in  common  type  of  lobar  and 
bronchopneumonia  and  often  in  the  so-called  ''secondary'' 
pneumonias  (those  developing  in  the  course  of  or  following  other 
diseases)  ;  the  pneuiiM^coccus.  Bacteriologically  four  U-pes  of 
pneumococcus  are  recognized,  these  having  been  designated  as 
Types  I,  II,  III  and  IV.  In  order  to  determine  the  type  of 
pneumococcus  present  in  any  case,  it  is  necessary  to  have  a  speci- 
men of  sputum  freshly  delivered  to  a  laboratory  especially 
equipped  for  this  work.  (See  Laboratory  Manual.)  The  State 
laboratory  supplies  a  serum  for  treatment  of  cases  incited  by  Type 
1  pneumococcus. 

Syphilis.  Infectious  agent;  a  specific  spirochaete  {Treponema 
pallidum),  present  in  the  discharges  from  open  lesions  (sores)  in 
active  cases.  Two  laboratory  procedures  are  of  value  as  aids  in 
the  diagnosis  of  syphilis — the  direct  examination  of  fresh  material 
for  the  detection  of  the  spirochaete,  and  \]\v  test  of  blood  for 
"complement-fixation"  (Wassermann  test).  For  the  detection 
of  the  organism  smears  are  ])repared  and  examined  wliih^  still 
fresh.  Special  apparatus  is  necessary  and  examinations  can  only 
be  made  at  laboratories  especially  equipped  for  tlio  puipu  <•. 


Public  Health  NuRsnxG  149 

The  complenient-fixation  test  of  samples  of  blood  from  cases  of 
suspected  syphilis  is  intricate  and  not  easy  to  understand  in  detail. 
However,  the  pul)lic  health  nurse,  a  part  of  whose  duty  frequently 
involves  the  investigation  of  cases  of  venereal  disease,  should  be 
able  to  interpret  reports  received  on  specimens  examined.  Here, 
as  elsewhere,  it  should  be  borne  in  mind  that  a  negative  report 
on  a  specimen  does  not  invariably  indicate  freedom  from  the  dis- 
ease. In  many  instances  the  examination  of  several  specimens 
may  be  necessary  before  definite  conclusions  can  be  drawn.  Be- 
sides being  of  value  in  diagnosis  the  blood  test  is  also  of  use  as 
indicating  the  results  of  treatment. 

Gonorrhea.  Infectious  agent;  the  gonococcus,  present  in  dis- 
ehai'gos  fioui  the  gt'iiito  urinary  organs  of  infected  persons. 
Specimens  of  discharge  are  obtained  by  making  a  thin  smear 
upon  a  microscopical  slide.  (See  Laboratory  Manual.)  The 
nurse,  before  undertaking  the  preparation  of  such  specimens, 
should  have  personal  instruction  from  a  physician  or  other  person 
familiar  with  the  technique  and  with  the  precautions  to  be. 
observed. 


150  State  Department  of  Health 

CHAPTER    Xn 
The  Nurse  in  Public  Health  Education 

The  fuiulainental  idea  of  public  health  education  is  to  secure 
community  action  on  public  health  problems.  Theoretically,  one 
may  suppose  that  if  the  more  intelligent  element  of  the  community 
can  be  made  to  respond,  the  result,  ultimately,  will  be  ''  to  leaven 
the  whole  loaf."  Practically,  howe^-er,  public  health  education 
means  reaching  the  whole  community  with  statements  of  facts  so 
clearly  phrased,  so  convincingly  presented  and  so  obviously 
important  that  *"  he  \vho  runs  may  read,"  and  individual  opinion 
becomes  public  opinion. 

The  impetus  in  changing  health  practices  may  come  from  the 
crowded  tenements  instead  of  the  more  spacious  home,  as  was 
witnessed  in  New  York  City  when  tenement  house  people  found 
that  antitoxin  administered  for  diphtheria  saved  life,  prevented 
others  from  getting  the  disease  and  shortened  the  period  of  quar- 
antine. Such  a  demand  for  diphtheria  antitoxin  arose  that  all 
physicians  who  wished  to  retain  their  patients  were  obliged  to 
administer  the  product  wherever  suspicion  existed  that  the  disease 
might  b'c  ])resent.  It  has  therefore  become  the  practice  of  healtli 
authorities  as  guardians  of  community  healtli  to  seek  to  carry  the 
newest  sanitary  and  hygienic  knowledge  to  the  individual  homo, 
and  to  present  it  in  S'uch  fashion  that  it  will  attract  the  attention 
of  the  people  most  likely  to  be  interested  in  the  ])ractical  value  of 
the  information.  For  this  reason  desira,ble  methods  of  dissemi- 
nating health  information  are  often  likened  to  those  employed  in 
marketing  oil  licatcis,  nutomobiles,  or  other  manufactured  product. 

Advertising  Health 

McHiods  E)npIoi/('(/.  First  in  importance  among  the  older 
ways  of  reaching  tlic  gciici'al  ])ulilic  with  infornuition  on  health 
const  rvatidu  may  be  reckoned  the  newspaper,  for  by  no  other 
means  can  so  hirge  an  audience  be  scM-ured.  Second  to  the  news- 
])aj)er  i?'  the  printed  circuhir  or  bulletin  of  six'cial  information. 

These  printed  messag(^s  should  be  supphMuented  with  lectures 
and  puldic  demonstrations  of  a  characttn-  which  will  attract  at- 
tention  and   create  discussion.      Motion   pict\ires,    lantern   slides. 


Public  Health  jS'uRsrxXG  151 

charts  aaid  panels  for  the  wall  which  may  be  studied  at  leisure, 
and  tlie  bulletin  board  for  health  news  are  among  the  measures 
used  for  stimulating  more  personal  interest  in  health  subjects. 
The  third  measure  is  the  most  personal  of  all,  that  which  deals 
directly  with  interested  individuals.  This  calls  for  personal  and 
family  teaching  and  demonstration,  and  may  be  given  at  the  clinic 
or  in  the  home.  It  provides  for  trial  and  correction  under  super- 
vision. Alone  it  reaches  fewer  people  than  the  other  two  methods ; 
in  conjunction  with  the  others  it  establishes  permanent  com- 
munity health  habits. 

The  Neivs'pafer.  Considering  fir-'.t,  the  newspaper  as  a  means 
of  reaching  the  public,  it  must  be  realized  that  while  it  is  the  most 
valual)le  agency,  it  is  at  the  same  time  the  most  difficult  to  secure 
as  an  ally.  The  publishing  of  a  newspaper  is  a  highly  specialized 
task.  The  'aim  of  every  good  paper  is  to  present  the  day's  news 
in  a  concise  and  attractive  form.  The  newspaper  has  neither 
time  nor  space  for  technical  discussions  —  everything  must  be  in 
a  form  to  be  quickly  and  easily  assimilated  by  the  average  reader. 
Under  usual  conditions  the  nurse  should  prepare  news  stories 
in  advance.  The  average  daily  newspaper  staff  is  pushed  for  time 
and  reporters  seldom  can  be  spared  to  prepare  articles  from  bare 
statistics  or  other  data.  The  article  must  present  either  a  new 
subject  or  a  new  angle  of  an  old  subject.  It  must  be,  above  all, 
concise  and  to  the  point.  The  editor  examines  all  copy  in  terms 
of  "  who,  what,  why,  when  and  where."  No  one  has  the  time  to 
supply  missing  details  except  the  writer. 

It  is  manifestly  impossible  to  lay  down  any  set  of  rules  or 
instructions  which  will  result  in  a  good  news  story.  However,  if  a 
person  writes  a  good  letter,  the  chances  are  that  the  same  person 
can  write  a  good  stoiy.  Perhaps  the  most  important  point  to  be 
kept  in  mind  is  that  the  good  story  has  a  "  human  angle  ".  The 
big  newspaper  story  is  merely  a  development  of  the  ordinary  com- 
munity item  of  gossip. 

In  preparing  a  story  statistics  should  be  given  a  wide  berth.  Tlie 
"  average  reader  "  does  not  understand  tabulations  and  few  news- 
papers will  print  them.  Statistics  can  be  interpreted,  however,  for 
popular  consumption,  for  they  can  always  be  arranged  to  show  the 


152  State  Department  of  Health 

possihilily  of  saving  lives  rather  than  ])resenting  mere  statements 
of  lives  lost. 

ill  submitting  an  article  to  a  newspaper,  there  are  three  rules 
which  must  be  observed.    These  are : 

1  Write  on  one  side  of  the  paper  only,  on  a  typewriter  if  pos- 
sible, with  double  space  between  the  lines. 

2  Leave  at  least  three  inches  blank  at  the  top  of  the  first  sheet. 

3  Submit  copy  to  the  ''  city  editor  "  of  the  paper  before  11  a.  m. 
on  the  day  of  publication,  if  it  is  an  afternoon  paper,  and  before 
8  p.  m.  on  the  day  before  publication,  if  it  is  a  morning  paper. 
Twenty-four  hours'  notice  is  better,  if  the  lapse  of  time  does  not 
destroy  the  news  value  of  the  story. 

There  are  some  things  which  are  desirable  to  get  before  the 
public  which  do  not  lend  themselves  to  news  stories.  These  may 
be  embodied  in  a  ''  Letter  to  the  Editor  "  and  thus  will  reach 
the  public,  although  much  effectiveness  is  lost.  Such  "  letters  " 
must  be  signed,  but  the  name  of  the  writer  may  be  concealed 
under  a  nom  de  plume  if  this  is  advisable. 

The  use  of  "  Letters  to  the  Editor "  are  of  value  chiefly  in 
arousing  a  community  to  discussion  of  a  subject,  especially  when 
it  is  desired  to  get  at  all  sides  of  a  question  regarding  which 
there  may  arise  some  latent  controversy.  In  a  recent  campaign  for 
a  tuberculosis  hospital,  for  example,  one  highly  original  worker 
carried  on  a  spirited  debate  with  himself  in  the  local  newspapers. 
Under  the  no7}i  de  plume  of  "  Veritas  "  and  "  Constant  Reader," 
he  argued  the  question  pro  and  con  for  weeks.  It  is  needless  to 
say  that  the  general  public  was  not  aware  of  the  deception  and  that 
"  Veritas  "  carried  his  point.  The  most  significant  result,  how- 
e\^er,  was  that  dozens  of  people  rose  to  defend  "  Veritas  "  when 
the  ''  Constant  Reader  "  letters  were  unjust  and  unfair.  This 
scheme  was  justified,  for  it  roused  the  community  to  action,  the 
one  result  sought. 

Another  sul)torfuge  resorted  to  occasionally  when  the  local 
newspapers  are  not  disposed  to  give  space  to  certain  facts  which 
the  worker  wishes  brought  before  the  public  is  to  secui-e  the  serv- 
ices of  a  prominent  local  citizen  as  a  speaker.  For  example,  in 
a  recent  tuberculosis  hospital  campaign,  it  was  desired  to  secure 
publicity  for  a  letter  written  by  two  young  women  ptrtients  at  the 


Public  Health  ]^URsrxG  153 

existing  sanatorium.  The  newspapers  had  printed  several  of 
these  letters  hut  were  disposed  to  put  them  in  an  out-of-the-way 
corner  of  the  paper. 

This  particular  letter,  however,  had  such  a  poignant  appeal  that 
it  deserved  wide  publicity.  It  was  secured  by  the  simple  means 
of  having  a  campaign  worker  read  the  letter  at  a  luncheon.  The 
inference  was  given  the  reporters  that  this  letter  was  of  so  great 
importance  that  the  speaker  had  thrown  aside  his  prepared 
address.  The  result  was  that  the  letter  was  printed  on  the  first 
page  under  large  headlines  with  consequent  discussion  throughout 
the  community. 

Frequently  the  nurse  will  have  opportunity  to  present  an 
extended  account  of  some  special  subject,  such  as  the  work  of  an 
infant  welfare  station.  Such  data  may  be  embodied  in  what  is 
called  a  "  Sunday  feature  story ".  It  should  be  accompanied 
by  photographs  showing  various  phases  of  the  work.  Most  news- 
papers are  glad  to  secure  such  stories  of  local  interest  and  fre- 
quently will  assign  a  special  writer  and  photographer  to  assist 
if  the  editor  is  convinced  in  advance  of  its  desirability. 

A  nurse  should  remember  that  the  community  which  supports 
her  work  is  entitled  to  know  something  of  its  progress.  Monthly 
reports  published  in  local  newspapers,  giving  facts  which  make  an 
emotional  appeal  without  revealing  the  identity  of  those  whose 
story  is  being  told,  are  one  of  the  best  measures  for  acquainting 
the  public  with  the  progress  of  the  work  and  developing  further 
interest  and  effort  in  the  promotion  of  public  health. 

A  very  large  part  of  a  community  may  be  reached  through 
the  press,  but  any  one  who  has  not  had  occasion  to  make  house 
to  house  visitations  would  scarcely  believe  how  large  a  portion  of 
the  population  of  urban  and  suburban  communities  rarely  read 
newspa})ers.  In  surveys  made  for  referenda  for  the  appropria- 
tion of  public  funds  for  the  establishment  of  health  seiwice  it  has 
been  found  that  a  large  proportion  of  citizens  will  not  be  reache<l 
unless  circulars,  bulletins,  special  circular  letters  and  other 
measures  are  also  used  to  acquaint  the  public  with  the  proposed 
undertaking.  In  piiblic  health  education  this  'class  of  people 
must  receive  special  consideration.     To  do  this,  insurance  com- 


154  State  .Dkl'akt-mijat  of  Health 

pauies  have  distributed  literature  calling  attention  to  ordinances 
which  have  become  a  dead  letter,  but  the  enforcement  of  which 
is  essential  to  the  health  of  their  policyholders.  When 
acquainted  with  facts  concerning  their  rights  the  people  have 
demanded  that  the  ordinances  be  enforced.  Child  welfare  organi- 
zations have  conducted  parades  which  have  carried  into  the  by- 
ways o,n  blazoned  placards  and  transparencies  slogans  of  the 
campaign,  leaflets  have  been  placed  under  front  and  back  doors 
inviting  everybody  to  attend  the  neighborhood  free  demonstration, 
and  windows  and  fences  have  been  placarded  with  ]X)sters  and 
)>ulletins  heralding  the  special  event  which  nobody  should  miss. 
Formal  lectures,  curb-stone  and  noon-hour  talks  and  other'  brief 
and  informal  addresses  have  ]yeen  utilized  to  deliver  a  s})ecial 
message  to  the  people.  On  nearly  all  of  these  occasions  specially 
prepai-ed  free  literature  has  been  ofl'ered  to  anyone  who  will  take 
it.  This  type  of  work  requires  careful  planning,  intelligent 
oliservation  of  the  reaction  of  the  people  and  prompt  seizure  of 
opportunities  resulting  from  interest  aroused.  Results  are  meas- 
ured not  in  the  amount  of  literature  distributed,  the  number  of  talks 
given,  or  the  size  of  the  listening  crowds,  but  in  the  tendency  of 
the  people  to  seek  further  information  on  the  subjects  such  as  is 
evidenced  by  an  increase  in  the  number  of  consultations  at  the 
clinics,  a  demand  for  more  literature  and  more  talks,  and  in  the 
case  of  child  welfare  work,  a  subsequent  decrease  in  the  local  loss 
of  child  life. 

Literature  for  free  distribution.  There  is  a  lai'ge  amount  of 
literature  giving  the  latest  scientific  informatio.n  regarding  health 
conservation  which  is  available  for  irov  distribution.  Federal, 
State  and  municipal  departments  of  health  and  education,  insur- 
ance companies,  philantliropic,  religious  and  scientific  organiza- 
tions have  carefully  prepared  material,  not  only  circulars,  pam- 
])li]('ts  and  ))()s1('rs  for  this  purpose,  ln;t  also  films  and  stereopticon 
slides,  A\hich  are  loaned  without  charge.  Much  scientific  knowl- 
edge of  lhis  sort  finds  its  way  to  the  people  in  pamphlet  form 
before  it  is  published  in  books. 

For  driving  home  the  lesson  in  any  given  locality  in  such 
fashion  as  to  secure  communitN'  action,  live  facts  concerninsx  that 


Public  Health  NuRsr^'G  155 

particular  place  should  be  presented.  To  do  this  charts  have  been 
found  a  good  means  of  visualizing  the  situation. 

Charts  and  chart  making.  The  equipment  necessary  in  pre- 
paring charts  suita])le  for  small  exhibits,  for  lecture  use  or  other 
purposes  is  simple.  Bristol  board  of  a  creamy  tint  can  be  pur- 
chased at  almost  any  stationery  store  and,  in  lieu  of  any  other 
material,  common  wrapping  paper  is  sufficient.  Given  a  yard 
stick  and  a  supply  of  soft  crayons  or  pencils,  almost  anything  in 
the  line  of  a  chart  can  be  prepared. 

The  most  common  faults  of  charts  are  that  they  are  too  small, 
that  the  lines  are  not  heavy  enough  and  that  the  data  is  not 
presented  in  its  simplest  or  most  attractive  form.  Charts  should 
be  at  least  20x25  inches  in  size  and  the  lines  of  the  drawings 
should  have  a  width  about  equal  to  the  thickness  of  a  half  dollar. 
^Yhether  or  not  a  chart  will  lie  legible  to  a  small  audience  can  be 
determined  by  holding  the  chart  at  arm's  length  and  examining 
it  through  half-closed  eyes.  If  the  lines  then  stand  out  boldly, 
they  will  be  visible  to  the  ordinary  assembly. 

A  point  to  remember  in  the  making  of  charts  in  colors  is  to 
restrict  the  colors  to  three  —  black,  green  and  red.  Black  is 
a  neutral  color,  and  should  be  used  for  general  titles  and  outlines. 
Green,  being  the  color  usually  associated  in  the  mind  with  safety, 
and  red  being  used  to  signify  danger,  these  colors  may  best  be 
utilized  to  indicate  favorable  and  unfavorable  conditions 
respectively.  Therefore,  in  presenting  a  chart  which  will  con- 
trast lives  lost  with  lives  which  might  be  saved,  put  the  titles  in 
black,  the  graph  expressing  the  number  of  lives  to  be  saved  in 
green  and  the  column  or  other  "  graph  "  expressing  the  number  of 
lives  lost  in  red. 

There  are  three  general  rules  in  regard  to  charts  which  must 
be  borne  in  mind  by  the  one  preparing  them.  These  rules,  like  the 
point  in  regard  to  use  of  colors,  are  not  easy  to  explain,  but  have 
been  developed  through  years  of  preparing  graphs  and  may  be 
said  to  be  based  upon  the  psychological  effect  observed  when  pre- 
senting the  charts  to  audiences  of  varied  composition.  These  rules 
are: 

1  Charts  of  a  single  dimension  are  the  least  likely  to  be 
misinterpreted. 


156  State  Departmeivt  of  Health 

2  The  general  arrangement  should  he  from  left  to  right,  as  one 
liolds  the  chart  before  him  or  faces  the  chart. 

3  The  title  must  be  so  complete  and  clear  that  misinterpreta- 
tion will  be  impossible. 

For  the  purposes  of  the  nurse,  five  forms  of  graphs  or  charts 
may  be  considered.  First  in  importance  is  the  spot  map ;  second, 
the  horizontal  and  vertical  bars;  third,  the  curve;  fourth,  the 
circle  with  sectors  and,  fifth,  the  organization  chart. 

The  spot  map  is  the  easiest  chart  to  prepare  and,  for  many 
pur])oses,  is  the  most  convincing.  There  are  few  cities  or  large 
municipalities  which  do  not  have  upon  file  in  their  department 
of  pulilic  works  or  engineering  blue  prints  of  the  city  or  village. 
Blue  or  white  prints  of  these  maps  usually  may  be  secured  at  no 
or  slight  cost.  The  so-called  white  print  is  the  most  desirable, 
for  in  this  all  lines  appear  in  dark  blue  or  black  against  a  white 
background,  while  in  the  ordinary  blue  print  the  lines  are  white 
against  a  blue  background. 

In  preparing  a  spot  map,  one  needs  only  accurate  morbidity 
or  mortality  statistics.  For  the  small  city  or  community,  it 
usually  is  desirable  to  take  statistics  for  a  term  of  years.  The 
extent  of  tuberculosis  in  a  rural  county  is  likely  to  appear 
negligible  if  based  upon  a  single  year,  while  for  a  period  of  five 
years  the  number  of  "  spots  "  will  convey  a  much  more  convincing 
impression.  The  "  spots  "  may  be  put  on  with  a  soft  pencil  or 
ink ;  tiny  pasters  or  pins  may  also  be  used. 

The  horizontal  and  vertical  bar  is  extremely  simple  to  use 
in  a  chart  and  is  scarcely  second  in  effect  to  the  spot  map.  For 
many  purposes  it  is  superior  to  any  other  form  of  chart.  For 
instance,  it  may  be  essential  to  convey  the  fact  that  the  infant 
mortality  problem  is  a  "one  wnrd  problem,"  and  the  relative 
height  of  the  bars,  with  the  addition  of  the  exact  figures  at  the 
top  of  each  liar,  will  bring  the  fact  home  conclusively.  Keference 
to  annual  reports  of  the  State  Depnrtment  of  Health  w'ill  show 
many  examples  of  the  use  of  the  bar  graph  and  illustrate  how^ 
simple  is  its  adaptation  to  the  presentation  of  statistics. 

The  curve  holds  a  peculiar  place  in  the  family  of  gi-aphs,  for 
while  it  is  extremely  simple  to  construct,  it  is  many  times  open 


Public  Health  NuRsnvG  157 

to  error  in  its  interpretation  by  the  layman.  It  therefore 
requires  explanation  to  avoid  misinterpretation.  It  is  usually 
adaptable  to  charts  where  one  wishes  to  show  the  incidence  of 
disease  or  the  development  of  an  epidemic. 

In  preparing  curve  charts,  it  is  well  to  have  the  vertical  guide 
lines  accurately  spaced  so  as  to  represent  a  certain  passage  of 
time  —  days,  weeks,  months  or  years.  This  permits  of  accurate 
charting  and,  if  the  lapse  of  time  is  cut  down  to  weeks,  will  bring 
out  facts  regarding  the  development  of  an  epidemic  not  available 
otherwise. 

The  average  nurse  seldom  will  wish  to  use  the  circle  with 
sectors,  not  only  because  its  construction  requires  familiarity  with 
certain  mathematical  formulae,  but  also  because  it  must  be  handled 
with  nicety  to  make  accurate  impressions  upon  a  lay  audience. 
A  forceful  variation  of  this  form  of  graph  is  in  the  use  of  a 
circle  within  a  circle.  A  circle  may  be  drawn  to  represent  the 
total  number  of  deaths  from  all  causes  and  at  all  ages  in  a  city 
for  a  given  year.  The  size  of  the  circle  is  determined  by  the 
usual  mathematical  formulae  for  calculating  areas.  A  second 
circle  is  then  prepared,  to  be  drawn  in  the  center  of  the  other. 
This,  for  example,  may  represent  the  number  of  deaths  under 
one  year  of  age.  The  result,  if  the  smaller  circle  is  blocked  in 
with  red,  is  to  secure  a  fair  representation  of  a  target  which,  with 
a  slogan  such  as  "  HIT  THE  BULLSEYE  IN  GREENWOOD,^' 
provides  a  striking  chart  for  educational  use. 

The  organization  chart  is  used  where  it  is  desirable  to  show 
how  community  activities  may  be  coordinated  and  simplified. 
Such  charts  are  widely  used  by  research  workers  to  indicate  lax  or 
complicated  methods  of  city  government,  and  while  not  always 
adaptable  to  the  use  of  the  nurse  in  health  work,  are  of  enough 
importance  to  justify  a  brief  description.  For  example,  a  nurse 
may  find  that  the  existing  public  health  nurses  are  not  working 
in  cooperation.  A  city  may  have  a  tuberculosis  nurse,  a  school 
nurse,  a  charity  nurse,  an  infant  welfare  nurse,  etc.,  and  yet  no 
provision  for  interchange  of  ideas  or  information.  A  simple 
chart  showing  the  tangled  skein  of  activity,  comparing  it  with 
the  direct  plan  desirable,  will  convince  the  group  of  officials  who 
may  be  too  prone  to  let  things  go  on  undisturbed. 


158  State  Depaktimknt  of  Healtit 

The  third  type  of  piil)lic  health  education  finds  its  field  in  the 
clinic  and  the  home.  It  is  that  personal  education  through  contact 
with  teachers,  physicians,  nurses  and  social  workers  in  school- 
room, clinic  and  home,  an  increase  in  the  demand  for  which  deter- 
mines largely  the  success  of  the  other  two  methods,  and  creates 
a  need  for  their  modification.  In  this  education  process,  teacli- 
ers,  physicians,  nurses  and  social  workers  are  learners  as  well  as 
instructors,  and  the  rapid  development  of  health  conservation  as  a 
pul)lic  concern  in  any  community  will  depend  as  much  upon  the 
o])en-minded  sincerity  of  this  latter  group  as  upon  other  factors. 
It  is  only  through  conference,  team-work  and  readjustments  of 
policy  that  health  work  keeps  up  with  the  needs  of  the  times.  In 
their  work  on  Dispensaries,  Davis  and  Warner  specify  that  "  the 
key  to  successful  guidance  of  policy  and  administration  in  any 
organization  is  to  bring  together  those  who  know  the  facts  on  which 
judgTuent  should  be  based  with  those  who  need  to  know  the  facts  in 
order  to  fi'ame  judgment."  Not  until  individuals  and  organiza- 
tions recog-nize  how  much  each  has  to  contribute  to  the  knowledge 
and  efiiciency  of  the  other,  and  how  great  is  their  interdependence 
for  successful  progressive  health  education  will  these  movements 
span  the  chasm  existing  between  the  need  of  the  individual  and 
available  resources  for  the  maintenance  of  health. 

Knowledge  and  deftness  in  application  of  the  knowledge  are 
necessary  either  in  clinic,  group  relations,  or  home  service.  Indus- 
try emphasizes  the  personality  of  the  worker  in  relation  to  his 
task  as  a  matter  for  careful  consideration  in  employing  him  for 
health  education  work.  An  acceptable  personality  added  to  knowl- 
edge of  health  conservation  measures  obtainable  or  creatable,  and  a 
habit  of  studying  the  ])sychology  of  the  crowd  and  the  individual 
are  qualifications  necessary  for  a  leader  who  would  ])roduce 
among  workers  of  the  world  a  determination  to  attain  health  for 
themselves  and  their  families,  to  create  a  supply  of  health 
resources  e(]ual  to  the  demand  and  to  materially  increase  the 
health  and  the  happiness  of  the  jniblic  generally. 

In  this  intimate  personal  education  work  the  i)ublic  health 
nurse  should  he  g'uided  by  good  ])edagogical  methods.  For  the 
nurse  to  do  the  thing  herself  exce})t  as  a  d(>monstration  is  not 
teaching.     Only  as  she  succeeds  in  aiding  the  individual  to  adopt 


PuBi,ic  Healti{  Nurskno  159 

good  hygienic  habits,  to  maintain  a  hygienic  environment  and  to 
become  an  ally  in  promoting  pul)lic  health  can  her  work  be  deemed 
educational.  Bed-side  nursing  is  one  thing ;  it  involves  correction  of 
conditions  which  the  individual  can  not  himself  correct;  it  is  essen- 
tial as  a  factor  in  promoting  public  health.  Teaching  others  to 
become  proficient  in  health  maintenance  is  an  entirely  different 
process.  For  this  reason  not  every  good  nurse  is  a  good  public 
health  nurse.  The  success  of  any  given  public  health  nurse  must 
be  gauged  by  what  her  pupils  learn  to  do  for  themselves  and  how 
keenly  they  utilize  what  they  learn,  rather  tlian  by  what  the  nurse 
herself  can  do.  If  her  work  is  good  the  pupils  tend  soon  to  gradu- 
ate from  her  tutelage,  although  if  they  have  found  her  a  good 
instructor  they  will  be  found  returning  for  her  counsel  and 
guidance  and  bringing  to  her  others  in  need  of  the  same  sort  of 
instruction. 


i60  State  Department  of  Health 


CHAPTER  Xni 

What  the   Nurse   Should   Know  about  Vital  Statistics 

It  is  perhaps  unfortunate  that  to  the  average  mind  mention  of 
vital  statistics  suggests  a  large  array  of  figures  and  tables,  intel- 
ligible only  to  those  who  have  been  specially  trained  in  this  line. 
A  better  conception  is  that  vital  statistics  are  statements  of  facts ; 
the  facts  of  human  life.  If  this  idea  is  once  firmly  fixed  in 
the  mind  of  the  reader  the  subject  immediately  becomes  more 
interesting  and  more  easily  understood. 

There  are  three  important  divisions  of  vital  statistics.  These 
are  the 

1  Births 

2  Marriages 

3  Deaths 

Some  authorities  also  include  divorces,  but  these  are  rarely 
included  in  any  state  reports.  . 

Stillbirths  are  not  tabulated  either  as  Ijirths  or  deaths,  but  under 
a  separate  classification.  The  law  requires  that  in  the  case  of  a 
stilll)irt]i  both  a  birth  and  death  certificate  shall  be  filed.  A  still- 
birth should  not,  however,  be  confused  with  a  living  birth,  no 
matter  how  short  a  time  the  child  may  live.  If  there  is  any 
respiration  it  is  a  living  birth  and  not  a  stillbirth. 

The  distinction,  however,  between  a  stillbirth  and  an  abortion 
or  miscarriage  is  somewhat  more  difficult,  but  if  the  period  of 
uterogestation  is  as  much  as  five  months  it  should  be  treated  as  a 
stillbirth  and  reported  as  such,  and  both  a  birth  and  death  certifi- 
cate should  be  filed. 

The  first  important  facts  to  know  in  studying  the  vital  statistics 
of  any  community  relate  to  the  population; — 

First,  the  number  of  people  in  the  area  to  be  studied. 

Second,  the  composition  of  the  population  by  sex  and  age, — 
namely,  the  number  of  males  and  the  number  of  females;  the 
number  of  young  children  and  the  number  of  very  old  people. 

The  color  is  important  where  there  are  sufficient  negroes  to 
affect  the  rate,  as  the  negro  death  rate  is  always  very  much  higher 
than  the  white.  I 


Public  Health  Nursing  161 

The  death  rate  for  very  young  children  and  for  very  old  people 
is  very  much  higher  than  it  is  for  those  in  the  adult  age  groups 
and,  consequently,  the  population  in  these  two  groups  as  com- 
pared to  the  middle  adult  group  is  exceedingly  important. 

'  Estimates  of  the  number  of  the  population  of  any  city,  county  or 
State  for  any  year  between  censuses  are  commonly  made  by  what 
is  known  as  the  arithmetical  method.  This  method  assumes  that 
the  rate  of  growth  during  the  present  censal  period  will  be  the 
same  as  for  that  immediately  preceding.     To  illustrate: 

The  city  of  "  K  "  had  a  population  June  1,  1900,  of  43,872, 
and  on  April  15,  1910,  of  50,982;  what  would  be  the  estimated 
population  July  1,  1915  ? 

(Operation) 

Elapsed  time,  June  1,  1900,  to  April  15,  1910  —  118yo  months. 

(Pop.  1910),  50,982—  (Pop.  1900),  43,872  —  7,110  gain  for 
1181/2  months. 

7,110  -T-  II8V2  =  60  gain  for  each  month. 

Elapsed  time  from  April  15,  1910,  to  July  1,  1915  =  621/2 
months. 

60x621/2+  (Pop.  1910),  50,982=^54,732  estimated  popula- 
tion July  1,  1915. 

For  statistical  purposes,  the  midyear  population  is  always  used. 

It  does  not  require  a  second  thought  to  realize  that  the  popula- 
tion of  a  pioneer  country,  made  up  almost  entirely  of  vigorous, 
rugged  men  in  the  prime  of  life,  would  tell  a  very  different  vital 
statistics  story  from  a  community  made  up  largely  of  children  and 
old  people  and  from  which  the  healthy  adult  men  and  women  had 
emigrated. 

What  is  termed  the  natural  growth  of  any  community  is  the 
number  of  births  less  the  number  of  deaths.  Where  the  births  and 
deaths  are  equal  the  population  is  stationary,*  but  even  in  these 
days  of  exceptionally  low  birth  rates,  in  most  parts  of  the  United 
States  the  birth  rate  is  usually  at  least  one  and  one-half  times  the 
death  rate. 

Most  communities  of  the  United  States  are  also  affected  very 
largely  by  immigration  and  emigration.     This  important  factor 

•  In  France  for  a  number  of  vears  before  the  war  the  births  and  deaths 
were  almost  equal  and  the  population  was  practically  stationary. 

6 


162  State  Department  of  Health 

depends  upon  many  different  things,  but  very  largely  upon  indus- 
trial and  agricultural  conditions. 

The  effect  of  marriage,  and  particularly  the  time  of  marriage, 
upon  the  movement  of  a  population,  is  manifest.  It  is  an  axiom 
that  delayed  marriages  result  in  small  families;  consequently  any- 
thing that  defers  marriage,  be  that  condition  economic  or  socio- 
logic,  directly  affects  the  movement  of  population.  There  are  many 
other  factors  which  directly,  or  indirectly,  affect  this  movement, 
but  it  seems  unnecessary  to  discuss  them  in  great  detail  at  this 
time. 

Rates 

The  births  and  deaths  in  a  community  are  usually  expressed  on 
the  basis  of  the  number  of  births  or  deaths  per  thousand  popula- 
tion. For  instance,  in  a  city  where  the  population  was  10,000 
and  there  were  250  births,  the  birth  rate  would  be  expressed  as  25 
per  1,000;  if  there  were  150  deaths,  the  death  rate  would  be 
expressed  as  15  per  1,000.  These  are  what  is  known  as  crude  or 
general  rates,  the  term  crude  being  the  one  more  commonly  used, 
and  it  applies  simply  to  the  total  number  of  births  or  deaths  in 
relation  to  the  whole  population.  This  will  always  be  the  first 
expression  of  a  community  rate,  but  it  is  subject  to  many  refine- 
ments, which  will  tend  to  make  one  locality  more  accurately  com- 
parable with  another. 

Some  statisticians  refer  to  the  science  of  statistics  as  the  science 
of  comparison,  and  the  primary  purpose  of  figuring  rates  of  any 
kind  is  for  this  purpose;  it  would  mean  but  little  to  say  that  the 
death  rate  of  New  York  was  15  per  thousand  if  we  did  not  know 
the  rates  of  other  states  or  countries,  but  in  order  to  make  rates  of 
value  for  the  purpose  of  comparison  great  care  must  be  exercised 
to  sec  that  they  are  really  comparable. 

Professor  Whipple  cites  the  following  incident  as  illustrating 
the  danger  of  erroneous  comparison.  During  the  Spanish-Ameri- 
can War  one  of  the  New  York  papers  printed  a  stoiy  in  which  it 
was  shown  that  the  death  rate  in  the  United  States  Navy  at  the 
time  of  war  was  9  per  1,000,  whereas  the  rate  in  New  York  City 
was  16  per  1,000,  giving  the  impression  that  it  was  safer  to  be  a 
sailor  in  the  United  States  Na\'y  in  war  time  than  it  was  to  live  in 
New  York  City. 


Public  Health  I^ursing  163 

No  consideration  was  made  of  the  fact  that  in  the  United  States 
IvTavy  the  personnel  was  composed  of  men  between  18  and  45  years 
of  age,  selected  after  a  rigid  physical  examination  (eliminating 
all  the  weak) ,  living  an  outdoor  life  under  the  most  hygienic  sur- 
roundings, well  fed  and  with  every  possible  care  exercised  to 
reduce  the  possibility  of  sickness  or  death  from  disease;  whereas 
m  New  York  City  we  find  every  possible  element  of  a  population 
—  the  sick  and  the  well,  the  infant  and  the  octogenarian,  the 
palace  and  the  slum,  the  clean  living  and  the  dissipated.  Cer- 
tainly a  moment's  thought  will  show  that  such  a  comparison  means 
little. 

When  we  consider  rates  as  applied  to  a  particular  class  of  the 
population,  we  make  what  is  known  as  specific  death  rates.  The 
death  rate  among  males  is  usually  higher  than  among  females,  and 
when  a  rate  is  made  by  taking  the  number  of  deaths  of  males  in 
comparison  with  the  number  of  the  male  population  and  the  num- 
ber of  deaths  of  females  in  comparison  with  the  female  population 
we  have  made  a  specific  death  rate  for  sex. 

If  we  figure  the  number  of  deaths  of  negroes,  Mongolians  or 
Indians  as  compared  with  the  number  of  negroes,  Mongolians  or 
Indians  in  the  population  we  have  then  made  a  specific  death  rate 
for  color  or  race. 

When  we  figure  the  number  of  deaths  of  children  under  one 
year  of  age  as  compared  with  the  population  under  one  year  of 
age  or  the  number  of  deaths  in  each  age  group,  compared  with  the 
number  of  people  in  each  age  group,  we  have  then  made  a  specific 
death  rate  for  age. 

Specific  death  rates  for  disease  are  exceedingly  important  and 
are  usually  figured  on  a  basis  of  the  number  of  deaths  from  any 
given  disease  per  100,000  of  the  population.  It  is  by  this  means 
that  we  are  able  to  compare  in  a  measure  the  healthfulness  of  a 
community.  If,  for  instance,  we  find  that  the  specific  death  rate 
for  typhoid  fever  is  much  higher  in  one  locality  than  in  another, 
it  indicates  what  Rosenau  describes  as  "  a  sanitary  short  circuit  " 
and  suggests  a  very  careful  survey  of  those  conditions  which  are 
known  to  produce  typhoid  fever.  If  the  specific  death  rate  from 
diarrhea  and  enteritis  in  children  under  two  years  is  higher  than 


164  State  Department  of  Health 

it  should  be,  it  indicates  the  necessity  of  very  definite  work  in 
regard  to  milk  suj)ply  and  the  better  education  of  mothers  in  the 
care  of  their  babies. 

Morbidity  statistics  are  the  statistics  of  sickness  and  should  not 
be  confused  with  mortality  statistics  or  statistics  of  death.  Unfor- 
tunately, perhaps,  the  average  American  citizen  objects  to  inquiry 
in  regard  to  his  health,  and  the  State,  therefore,  does  not  collect 
any  records  of  sickness  except  those  toward  the  prevention  and 
control  of  which  public  measures  are  directed. 

Morbidity  rates  are  usually  expressed  in  the  number  of  cases 
per  100,000  population. 

The  fatality  rates  of  a  disease  refer  to  the  percentage  of  the 
cases  which  prove  fatal. 

Specific  death  rates  are  valuable  for  many  comparisons  and  are 
frequently  used.  For  the  purpose,  however,  of  a  general  com- 
parison as  between  communities  another  form  of  rate  is  used 
which  is  called  a  corrected  or  standardized  death  rate. 

These  are  described  by  the  United  States  Bureau  of  the  Census 
as  follows : 

"  The  term  '  corrected  rates  '  is  employed  to  signify  a  rate 
in  the  computation  of  which  allowance  has  been  made  for 
difference  in  age  and  sex  constitution  of  the  population. 

When  obtaining  corrected  death  rates  the  usual  method  is 
to  select  a  standard  population,  definitely  distributed  into 
certain  groups  with  respect  to  age  or  age  and  sex. 

The  specific  death  rates  of  any  area  as  computed  for  the 
same  groups  are  then  applied  to  corresponding  subdivisions 
of  the  standard  poimlation,  the  result  being  the  number  of 
deaths  which  would  have  occurred  in  each  grouj)  of  the  stand- 
ard population  had  its  death  rate  been  the  same  as  that  of  the 
same  group  in  the  given  area. 

The  summation  of  the  deaths  that  would  have  occurred  in 
all  the  groups  of  the  standard  poinilation  gives  the  total 
number  of  deaths  in  the  standard  pojmlation  corresponding 
to  the  observed  specific  death  rates  in  the  given  area,  and  the 
division  of  this  total  by  the  standard  population  yields  the 
corrected  death  rate." 


Public  Health  Nursing  165 

The  standard  population  which  has  been  generally  accepted  by 
registration  officials  within  the  past  few  years  is  the  standard  mil- 
lion of  England  and  Wales,  as  shown  by  the  census  of  1901  and  is 
appended  herewith. 

Standard  Million,  England  and  Wales,  1901 

Age  Period  Both  Secoes  Males  Females 

All  Ages    1,000,000  483,543  516,467 

Under  5  years 114,262  57,039  57,223 

5-9  years   107,209  53,462  53,747 

10-14  years   102,735  51,370  61,365 

15-19  years   99,796  49,420  50,376 

20-24  years   95,946  45,273  50,673 

25-34  years   161,579  76,425  85,154 

35-44  years    122,849  59,394  63,455 

45-54  years    89,222  42,924  46,298 

55-64  years   69,741  27,913  31,828 

65-74  years   33,080  14,691  18,389 

75  years  and  over 13,581  5,632  7,949 


The  infant  mortality  rate  is  perhaps  less  understood  than  any 
other  form  of  rate.  The  infant  mortality  rate  is  the  comparison 
of  the  number  of  deaths  of  children  under  one  year  of  age  with  the 
number  of  births  which  occurred  during  the  same  period,  and  is 
expressed  in  the  number  of  deaths  per  thousand  births.  This, 
obviously,  has  nothing  to  do  with  deaths  at  other  age  periods. 
This  rate  is  frequently  unreliable  because  births  in  many  localities 
are  not  all  reported,  and  if  even  a  few  births  are  unreported  in  a 
community  and  the  deaths  are  all  reported  it  makes  the  rate  appear 
higher  than  it  really  is. 

In  the  consideration  of  the  infant  mortality  rate,  then,  it  is 
essential  to  carefully  study  the  birth  registration  of  the  com- 
munity and  thus  be  assured  of  its  completeness  before  an  attempt 
is  made  to  determine  an  infant  mortality  rate. 

Marriage  rates  are  usually  expressed  in  the  terms  of  the  number 
of  marriages  per  1,000  population.  Some  authorities  prefer, 
however,  to  express  the  number  of  people  married  per  1,000  popu- 
lation, which  rate  is  just  double  the  foregoing. 

To  understand  vital  statistics  it  is  essential  that  we  understand 
the  laws  under  which  they  are  collected. 


166  State  Department  of  Health 

In  this  State  the  law  provides  for  a  system  of  local  registrars, 
one  in  each  city,  village  and  town  and  state  hospital,  charitable,  or 
penal  institution.     In  all  there  are  1,485  registration  districts. 

In  the  case  of  birth  the  law  requires  a  certificate,  fully  and  com- 
pletely made  out,  to  be  filed  with  the  local  registrar  within  five 
days  by  the  physician  or  midwife  in  attendance,  and  the  law  pro- 
vides a  heavj  penalty  for  failure  so  to  do.  If  there  is  no  attend- 
ing physician  or  midwife  the  law  fixes  the  responsibility  upon  the 
father,  mother,  or  householder,  in  the  order  named. 

In  the  case  of  death  the  law  requires  that  the  undertaker  shall 
fill  out  a  death  certificate,  securing  the  infonnation  as  to  the  name 
of  the  decedent,  the  sex,  color,  conjugal  condition,  date  of  birth, 
age,  occupation  and  birthplace,  name  and  birthplace  of  father, 
maiden  name  and  birthplace  of  mother,  and  that  he  shall  cause  the 
certificate  to  be  signed  by  the  informant  from  whom  he  obtains  this 
information.  He  must  then  present  the  certificate  to  the  physician 
last  in  attendance  on  the  case,  who  must  state  the  time  of  his 
attendance,  the  cause  of  death  and  its  duration,  the  contributory 
cause,  if  any,  and  its  duration,  and  must  sign  and  date  the  same. 

The  undertaker  then  states  the  place  of  burial,  or  removal,  and 
the  date  thereof,  signs  and  presents  the  completed  certificate  to 
the  local  registrar,  in  exchange  for  which  he  receives  a  burial,  or 
removal  permit.  A  heaAy  penalty  attaches  to  the  burial,  removal 
or  other  disposition  of  a  dead  body  without  first  receiving  a  permit 
for  so  doing. 

Penalties  are  also  provided  for  the  sexton  or  person  in  charge 
of  any  cemetery  who  permits  an  interment  without  a  burial  permit 
being  presented  to  him. 

The  local  registrars,  after  duly  entering  the  certificates 
received  in  their  own  records,  send  the  original  certificates  of  both 
births  and  deaths  to  the  State  Department  of  Health,  where  they 
are  classified,  indexed  and  filed  as  a  permanent  record.  Certifi- 
cates of  birth  for  school  and  work  purposes  and  copies  of  death 
records  for  insurance,  pension  and  other  legal  purposes  are  issued 
on  request. 

There  are  three  important  reasons  why  births  and  deaths  should 
be  registered.  These  are  set  forth  by  the  Bureau  of  the  Census  a* 
follows : 


Public  Health  Nursing  167 

First,  the  protection  of  the  rights  of  an  individual  and  of  the 
community  (legal  use)  ; 

Second,  the  protection  of  the  lives  and  the  health  of  the  people 
(sanitary  use)  ; 

Third,  the  knowledge  of  the  movement  of  population  (demo- 
graphic use). 

The  prompt  registration  of  births  provides  a  legal  record  which 
is  of  value  to  the  child  in  many  ways ;  for  instance,  it  protects  not 
only  the  child  in  its  education  hut  also  the  educational  institutions, 
because  with  the  positive  evidence  of  the  age  of  each  child  it  is  not 
possible  to  use  the  schools  as  a  nursery  by  sending  children  at  an 
age  when  the  mind  is  not  sufficiently  developed  to  permit  its 
being  taught.  Again  it  insures  that  the  child  shall  not  be  with- 
dravni  from  school  until  those  years  have  elapsed  which  the  law 
requires  shall  be  given  over  to  education,  and  the  child  can  not, 
therefore,  be  forced  to  work  by  parents  who  desire  to  exploit  its 
wage-earning  power.  The  child  as  a  potential  citizen  is  protected 
in  its  rights  of  citizenship,  in  the  right  to  vote,  in  the  right  to 
inherit  and  many  other  important  ways. 

From  a  sanitary  standpoint  we  can  not  hope  to  reduce  the  awful 
life  waste  caused  by  infant  mortality  unless  we  know  where  the 
babies  are  and  can  promptly  put  into  the  hands  of  mothers,  where 
it  is  needed,  prompt  and  proper  instruction. 

The  registration  of  deaths  is  important  for  many  legal  reasons, 
as  well  as  for  the  purposes  of  insurance,  inheritance,  and  succes- 
sion. 

"We  are  more  familiar,  however,  with  the  sanitary  reason  for 
death  registration,  as  it  enables  us  promptly  to  find  the  plague 
spots  and  to  take  measures  to  eradicate  them.  We  can  not  success- 
fully fight  disease  if  we  do  not  know  where  it  is  and  what  havoc  it 
is  causing. 

The  demographic  reason  for  the  registration  of  both  births  and 
deaths  is  that  we  may  understand  the  movement  of  population, 
the  sources  from  which  it  is  being  renewed  and  the  causes  of  its 
depletion. 

IN'ONRESIDENT    DeATHS 

If  it  is  desired  to  study  some  city  closely,  allowance  may  be 
made  for  what  is  known  as  nonresident  deaths.     Where  there  are 


168  State  Department  of  Health 

considerable  hospital  facilities  in  a  city,  or  where  there  may  be  a 
public  institution  where  people  are  comnutted  by  process  of  law,  or 
where  they  resort  for  treatment  of  disease,  this  may  be  a  marked 
factor  in  producing  a  high  death  rate.  In  those  cases  the  non- 
resident deaths  may  be  omitted  and  the  true  death  rate  for  resi- 
dents only  be  thus  determined,  but  Avhen  this  is  done  the  com- 
parative value  of  the  rate  is  vitiated,  as  it  would  be  misleading  to 
compare  this  with  any  other  city  where  the  rate  had  not  been 
similarly  treated,  as  almost  eveiy  city  has  some  hospitals  and 
some  nonresident  deaths. 

If  it  is  desired  to  compare  the  relative  healthfulness  of  two 
cities,  however,  the  elimination  of  nonresident  deaths  from  both 
will  aiford  valuable  data  for  detailed  study. 

It  is  a  difficult  problem  to  attempt  the  general  omission  of  non- 
resident deaths  and  their  reassignment  to  other  localities,  and 
until  more  definite  procedure  has  been  agreed  upon  by  registration 
officials,  it  is  best  to  confine  such  action  to  special  studies  of 
restricted  areas. 

Perhaps  the  practical  use  of  vital  statistics  may  be  sho"^ii  in  the 
following  study  which  was  undertaken  to  demonstrate  the  value 
to  the  community  of  public  health  nursing  as  a  whole,  and  in  par- 
ticular, the  employment  of  a  special  baby  nurse. 

In  a  city  which  had  a  population  of  about  50,000,  the  study 
was  made  to  cover  the  months  of  May,  June,  July  and  August  in 
the  years  1913  and  1914,  and  included  only  the  deaths  of  children 
under  two  years  of  age. 

Total  Deaths  Four  Months 

1913 53 

1914    34 

Gain 35 . 8% 


Months  of  Occurrence 

1013  1914 

May 10  9 

June 6  6 

July 10  8 

August 27  11 


Public  Health  Nursing 


169 


The  Causes  of  Death 

Diarrhea  and  enteritis 

Congenital  debility   

Premature  births   

Other  diseases  of  early  infancy 

Convulsions  of  infants 

Bronchitis 

Tubercular  peritonitis   

Whooping  cough  

Bronchopneumonia     

Malaria 

Cerebrospinal  meningitis    

Tetanus 

Congenital  malformation    

Purulent  septicaemia   

Measles 

Food  poisoning   

Violence 

Ages 

Under  1  week 

Over  1  week  and  under  1  month 

Over  1  month  and  under  6  months 

Over  6  months  and  under  1  year 

One  to  two  years 


1913 

1914 

28 

4 

6 

11 

4 

4 

3 

0 

2 

1 

1 

0 

1 

0 

2 

3 

2 

2 

1 

0 

1 

0 

1 

0 

0 

3 

0 

1 

0 

2 

0 

1 

1 

2 

1913 

1914 

14 

10 

3 

4 

14 

7 

13 

4 

9 

9 

An  examination  of  the  causes  of  death  will  immediately  reveal 
that  this  veiy  remarkable  improvement  was  due  to  a  decrease  in 
the  number  of  deaths  from  diarrhea  and  enteritis  from  28  to  4. 
In  searching  for  some  explanation  of  this  reduction,  it  was  discov- 
ered that  the  summer  of  1913  was  extremely  hot  while  that  of 
1914  was  quite  cool.  Under  more  favorable  weather  conditions, 
milk  naturally  was  less  quickly  spoiled,  children  slept  better  and 
thus  were  able  to  build  up  a  greater  resistance  to  infection.  It  is 
therefore  reasonable  to  suppose  that  cooler  weather  was  an  impor- 
tant factor  in  reducing  deaths  from  this  cause. 

A  further  survey  of  the  situation  revealed  the  fact  that  in  1914 
the  city  had  greatly  improved  its  supervision  of  milk  supplies  and 
the  quality  of  milk  furnished  throughout  the  city  was  far  better 
than  the  preceding  year.  Milk  stations  had  been  established,  and 
even  the  poorest  persons  were  able  to  secure  a  high-grade  milk  for 
their  babies. 


170  State  Department  of  Health 

Another  imjjortant  consideration  was  the  fact  that  for  the  year 
preceding  the  summer  of  1914  much  had  been  done  in  the  way  of 
baby  clinics  and  of  general  educational  propaganda  for  the  insti-uc- 
tion  of  mothers  in  the  general  care  of  their  babies. 

These  three  elements,  together  with  the  work  of  the  nursing 
association,  were  probably  in  a  large  measure  responsible  for  the 
reduction  of  this  loss  of  life. 

It  will  be  observed  by  comparison  of  the  age  tables  that  the 
entire  saving  occurred  among  babies  under  one  year  of  age,  the 
deaths  between  one  and  two  years  being  the  same  in  both  years. 

It  will  be  noted,  however,  that  in  the  three  causes,  congenital 
debility,  premature  births  and  other  diseases  of  early  infancy, 
there  were  13  deaths  reported  in  1913,  whereas  there  were  15  in 
1914.  The  reduction  in  deaths  from  these  causes  is  generally  con- 
ceded to  be  a  problem  of  prenatal  work,  and  it  is  evident  that  but 
little  had  been  done,  at  least  successfully,  in  this  regard  during 
this  period. 

This  little  study  and  these  comments  are  submitted  simply  to 
show  that  the  vital  statistics  open  the  way  for  a  study  of  those 
social  and  medical  elements  which  largely  affect  the  death  rate. 

Caution 

Great  care  should  always  be  exercised  not  to  be  misled  by  con- 
clusions or  rates  based  upon  a  small  population  or  a  small  number 
of  incidents. 

A  health  officer  of  a  small  community  was  much  disturlied  when 
informed  by  one  of  his  friends,  as  a  joke,  that  50  per  cent  of  the 
deaths  in  his  district  during  the  preceding  month  were  caused  by 
{ippendicitis;  after  some  excitement  he  discovered  that  there  had 
been  two  deaths,  one  of  which  was  from  that  disease. 

Death  rates  based  upon  a  small  population  or  a  short  period 
must  be  carefully  used  or  the  results  will  be  misleading. 

Criticism  is  occasionally  made  of  the  publication  of  monthly 
birth  and  death  rates,  and  this  is  usually  because  the  purpose  of 
80  doing  is  not  generally  understood. 

The  fluctuation  of  the  monthly  death  rate  is  usually  due  to 
some  unusual  epidemic  or  catastrophe,  and  is,  therefore,  an  indica- 


Public  Health  ISTuksing  171 

tion  of  danger,  calling  into  action  those  forces  provided  by  law  to 
prevent  undue  loss  of  life  from  any  cause.  Obviously  there  can  be 
no  possible  connection  between  these  monthly  rates  and  the  annual 
rates  as  exceptional  months  are  frequently  compensated  in  fol- 
lowing months.  In  every  community,  there  are  always  a  number 
of  people  of  great  age  or  invalids  who  might,  under  favorable  con- 
ditions, linger  for  months  on  the  brink  of  the  grave,  but  a  marked 
thermal  change,  or  an  epidemic  of  some  kind,  such  as  measles, 
whooping  cough,  influenza  or  grippe,  will  prove  too  much  for  their 
weakened  resistance  and  the  death  rate  goes  up  accordingly. 

A  health  officer  should  leam  to  read  the  death  rates  in  his  com- 
munity as  a  mariner  reads  his  barometer,  and  be  prepared  to 
battle  with  the  elements  that  destroy  life. 

In  a  large  area,  such  as  the  State  of  New  York,  slight 
changes  do  not  make  notable  fluctuations  in  the  death  rate.  It 
takes  an  increase  or  decrease  of  858  deaths  in  a  month  to  increase 
the  monthly  death  rate  one  unit,  or  from  15.0  per  1,000  to  16.0 
per  1,000  or  decrease  it  to  14.0  per  1,000.  In  a  small  conmiunity 
the  changes  are  much  more  marked.  In  Niagara  Falls,  with  a 
population  of  44,585,  the  number  of  deaths  varied  in  1916  from 
a  minimum  of  33  in  November  to  a  maximum  of  85  in  May,  and 
the  death  rate  for  these  months  from  9.0  to  22.5  per  1,000.  In 
that  city  a  change  of  four  deaths  in  a  monthly  rate  would  have 
made  a  difference  of  1.3  or  from  14.0  to  15.3  per  1,000.  In  Lock- 
port,  with  a  population  of  18,833,  the  numl)er  of  deaths  varied  in 
1916  from  19  with  a  death  rate  of  12.3  in  June  to  30  with  a  death 
rate  of  18.8  in  January.  Here  an  increase  of  one  death  would 
have  increased  the  rate  from  18.0  to  18.9  per  1,000.  Great  care 
must  be  taken  to  avoid  error  in  the  intei-pretation  of  these  rates, 
particularly  when  applied  to  a  small  population. 

If  it  is  desired  to  determine  the  annual  rate  instead  of  the 
monthly  rate,  this  may  be  done  by  adding  the  number  of  deaths  in 
any  month  to  the  eleven  preceding  months  and  dividing  the  sum 
by  the  population.  This  gives  an  annual  rate  based  upon  the 
assumption  that  the  number  of  deaths  for  the  balance  of  the  year 
will  equal  the  number  for  the  same  period  of  the  preceding  year. 

The  monthly  rates  and  the  annual  rates  are  two  different  things 


172  State  DErAHTMENT  of  Health 

and  should  be  used  for  different  purposes.  The  sharp  fluctuations 
which  may  occur  in  monthly  rates  are  typical  of  acute  disease  con- 
ditions. It  is  probable  that  in  many  cases  by  the  time  these  rates 
are  published  the  cause  of  the  sharp  increase  has  been  removed  or 
is  under  control.  On  the  other  hand,  a  slowly  increasing  annual 
death  rate  compared  month  by  month  is  typical  of  what  might  be 
termed  a  chronic  condition,  and  means  that  there  is  some  disturb- 
ing element  at  work  that  should  be  sought  out  and  corrected. 


Public  Health  Nursing  173 


CHAPTER   XIV 
The  PubUc  Health  Nurse  and  Child  Welfare  Activities 

There  is  no  more  important  field  of  activity  on  the  part  of  the 
public  health  nurse  than  that  which  pertains  to  the  prevention  of 
disease  and  of  deaths  among  infants  and  young  children.  Child 
welfare  work  has  assumed  a  greater  importance  than  evei-  since  the 
World  War,  for  the  protection  and  conservation  of  childhood  is 
not  alone  a  home  problem  but  is  one  that  affects  the  community 
and  the  nation.  The  public  health  nurse  should  be  prepared  to 
supervise  the  health  and  surroundings  of  the  child  from  the 
earliest  prenatal  through  the  adolescent  period. 

The  infant  mortality  rate  is  the  comparison  of  the  number  of 
deaths  under  one  year  of  age  with  the  number  of  births  which 
occurred  during  a  given  year,  and  is  expressed  in  the  number  of 
deaths  per  thousand  births.  Stillbirths,  which  constitute  about  4 
per  cent  of  all  births,  are  not  included  in  those  used  in  computing 
infant  mortality  although  both  a  birth  and  a  death  certificate  are 
required  to  be  filed.  If  a  baby  breathes  after  birth  it  is  not  a  still- 
birth. To  obtain  the  infant  mortality  rate,  divide  the  number  of 
deaths  under  one  year  of  age  during  the  year  by  the  number  of 
births  occurring  during  the  same  period  and  multiply  by  lOO'O. 

For  example, —  a  city  has  250  births  in  one  year  and  30  deaths 
under  one  year  of  age. 

—      X    1000=   120 
25D 

The  infant  mortality  rate  is  120  per  1000  living  births. 

Before  undertaking  a  health  program  for  any  community,  then, 
one  should  know  its  infant  mortality  rate.  One  should  also 
know  in  what  direction  it  is  tending.  A  community  may  have 
an  infant  death  rate  which  is  not  high,  and  yet  it  may  be  slowly 
rising.  Such  a  condition  should  lead  to  a  study  of  the  causes  pro- 
ducing it  in  order  that  they  may  be  corrected. 

Sir  Arthur  Newsholme  states  that  "  infant  mortality  is  the 
most  sensitive  index  we  possess  of  social  conditions  and  a  high 


1Y4:'  State  Department  of  Health 

death  rate  among  the  babies  indicates  conditions  which  affect  not 
alone  the  little  children  but  the  entire  community."  A  large  per- 
centage, possibly  one-third,  of  infant  deaths  can  be  prevented. 
Why,  if  preventable,  are  they  not  prevented  ?  To  answer  this 
question  intelligently  one  must  know  where  and  why  the  babies  die 
and  for  this  information  recourse  to  vital  statistics  must  he  had. 

A  study  of  the  causes  of  deaths  in  the  first  year  of  life  reveals 
many  interesting  facts.  Nearly  one-half  occur  within  the  first 
four  weeks  after  birth  and  the  number  of  deaths  then  diminish 
month  by  month.  The  deaths  which  occur  in  the  first  month  include 
those  due  to  congenital  malformation,  debility  and  prematurity, 
and  are  the  result  of  conditions  which  affect  the  child  before  it  is 
boi-n. 

Since  it  has  been  shown  through  a  careful  study  of  statistics 
that  nearly  one  half  of  all  infant  deaths  occur  during  the  first 
month  of  life  it  is  obvious  that  if  the  baby  welfare  service  is  going 
to  have  a  chance  at  saving  these  lives  it  must  find  some  way  to 
give  care  to  the  mother  during  her  entire  pregnancy.  This  care 
cannot  be  given  to  a  gi'oup;  it  must  be  individual  care.  As  it 
has  been  found  that  it  is  practically  impossible  to  get  any  con- 
siderable number  of  prospective  mothers  to  attend  clinics  or  to 
consult  a  physician  upon  invitation,  child  welfare  organizations 
have  sent  nurses  to  homes  of  enciente  women  to  get  them  under  the 
care  of  a  physician.  This  method  is  found  to  produce  results.  The 
nurse  may  meet  with  little  response  during  her  first  visits ;  here  as 
in  other  fields  personality  is  a  large  factor,  but  if  the  nurse  is 
enthusiastic  over  child-saving  and  at  the  same  time  tactful  she 
will  find  that  a  large  proportion  of  the  prospective  mothers  will 
ultimately  be  persuaded  to  accept  her  recommendation. 

Quite  recently  the  Children's  Bureau  of  the  U.  S.  Department 
of  Labor  has  published  the  "  Minimum  Standards  of  Child  Wel- 
fare" adopted  by  the  Washington  and  Eegional  Conferences  on 
'^hild  Welfare.  The  following  extract  is  taken  from  their  Bureau 
Publication  No.  62 : 


Public  Health  Nursing  175 


"  Minimum  Standards  for  Public  Protection  of  the  Health 
OF  Mothers  and  Children 
Maternity 
"  1    Maternity  or  prenatal  centers,  suflScient  to  provide  for  all 
cases  not  receiving  prenatal  supervision  from  private  physi- 
cians.    The  work  of  such  a  center  should  include : 

(a)  Complete  physical  examination  hy  physician  as  early  in 

pregnancy  as  possible,  including  pelvic  measure- 
ments, examination  of  heart,  lungs,  abdomen,  and 
urine,  and  the  taking  of  blood  pressure;  internal 
examination  before  seventh  month  in  primipara; 
examination  of  urine  every  four  weeks  during  early 
months,  at  least  every  two  weeks  after  sixth  month, 
and  more  frequently  if  indicated ;  Wassermann  test 
whenever  possible,  especially  when  indicated  by 
symptoms. 

(b)  Instruction  in  hygiene  of  maternity  and  supervision 

throughout  pregnancy,  through  at  least  monthly  vis- 
its to  a  maternity  center  until  end  of  sixth  month, 
and  every  two  weeks  thereafter.  Literature  to  be 
given  mother  to  acquaint  her  with  the  principles  of 
infant  hygiene. 

(c)  Emplo}Tnent  of  a  sufficient  number  of  public  health 

nurses  to  do  home  visiting  and  to  give  instructions  to 
expectant  mothers  in  hygiene  of  pregnancy  and  early 
infancy ;  to  make  visits  and  to  care  for  patients  in 
puerperium ;  and  to  see  that  every  infant  is  referred 
to  a  children's  health  center. 

(d)  Confinement  at  home  by   a  physician  or   a  properly 

trained  and  qualified  attendant,  or  in  a  hospital. 

(e)  Nursing  service  at  home  at  the  time  of  confinement  and 

during  the  lying-in  period,  or  hospital  care. 

(f )  Daily  visits  for  five  days,  and  at  least  two  other  visits 

during  second  week  by  physician  or  nurse  from 
maternity  center. 


1Y6  State  Department  of  Health 

"  (g)   At  least  ten  days'  rest  in  bed  after  a  normal  delivery, 
with  sufficient  household  service  for  four  to  six 
weeks  to  allow  mother  to  recuperate, 
(h)   Examination  by  physician   six  weeks   after   delivery 
before  discharging  patient. 

"  Where  these  centers  have  not  yet  been  established,  or  where 
their  immediate  establishment  is  impracticable,  as  many  as  possi- 
ble of  these  provisions  here  enumerated  should  be  carried  out  by 
the  community  nurse,  under  the  direction  of  the  health  officer  or 
local  physician. 

2  Clinics,  such  as  dental  clinics  and  venereal  clinics,  for  needed 

treatment  during  pregnancy. 

3  Maternity  hospitals,  or  maternity  wards  in  general  hospitals, 

sufficient  to  provide  care  in  all  complicated  cases  and  for  all 
women  wishing  hospital  care;  free  or  part-payment  obstetri- 
cal care  to  be  provided  in  every  necessitous  case  at  home  or  in 
a  hospital. 

4  All   midwives  to  be  required  by  law  to  show  adequate  training, 

and  to  be  licensed  and  supervised. 

5  Adequate  income  to  allow  the  mother  to  remain  in  the  home 

through  the  nursing  period. 

6  Education  of  general  public  as  to  problems  presented  by  mater- 

nal and  infant  mortality  and  their  solution. 

"  Infants  cmd  Preschool  Children 

1  Complete  birth  registration  by  adequate  legislation  requiring 

reporting  within  three  days  after  birth. 

2  Prevention  of  infantile  blindness  by  making  and  enforcing  ade- 

quate laws  for  treatment  of  eyes  of  every  infant  at  birth  and 
supervision  of  all  positive  cases. 

3  Sufficient  number  of  children's  health  centers  to  give  health 

instruction  under  medical  supervision  for  all  infants  and 
children  not  under  care  of  private  physician,  and  to  give 
instruction  in  breast  feeding  and  in  care  and  feeding  of  chil- 
dren to  mothers,  at  least  once  a  month  throughout  first  year, 
and  at  regular  intervals  throughout  preschool  age.  This  cen- 
ter to  include  a  nutrition  and  dental  clinic. 


Public  Health  Nursing  1'J"J' 

"  4  Children's  health  center  to  provide  or  to  cooperate  with  suf- 
ficient number  of  public  health  nurses  to  make  home  visits  to 
all  infants  and  children  of  preschool  age  needing  care  —  one 
public  health  nurse  for  average  general  population  of  2,000. 
Visits  to  the  home  are  for  the  purpose  of  instructing  the 
mother  in  — 

(a)  Value  of  breast  feeding. 

(b)  Technic  of  nursing. 

(c)  Technic  of  bath,  sleep,  clothing,  ventilation,  and  general 

care  of  the  baby,  with  demonstrations. 

(d)  Preparation  and  technic  of  artificial  feeding. 

(e)  Dietary  essentials  and  selection  of  food  for  the  infant 

and  for  older  children. 

(f )  Prevention  of  disease  in  children. 

5  Dental  clinics ;  eye,  ear,  nose,  and  throat  clinics ;  venereal  and 

other  clinics  for  the  treatment  of  defects  an.d  disease. 

6  Children's  hospitals,  or  beds  in  general  hospitals,  or  provision 

for  medical  and  nursing  care  at  home,  sufficient  to  care  for  all 
sick  infants  and  young  children. 

7  State  licensing  and  supervision  of  all  child  caring  institutions 

or  homes  in  which  infants  or  young  children  are  cared  for. 

8  General  educational  work  in  prevention  of  communicable  disease 

and  in  hygiene  and  feeding  of  infants  and  young  children." 

Infant  mortality  and  sociology  are  closely  related.  The  prob- 
lems of  how  to  deal  with  ignorance,  inexperience  and  poverty, 
how  to  restrict  the  emplo}anent  of  women  during  the  period  of 
child  bearing,  how  to  care  properly  for  the  mother  who  is  unmar- 
ried, how  to  provide  proper  facilities  especially  needed  in  rural 
districts  at  confinement,  and  how  to  secure  better  housing  and 
living  conditions  for  working  people  must  be  met  if  the  number  of 
deaths  of  infants  during  the  first  four  weeks  is  to  be  materially 
reduced.  Deaths  from  gastrointestinal  diseases  have  been  materi- 
ally reduced  by  teaching  and  assisting  mothers  to  breast-feed  their 
babies,  to  guard  them  against  the  fonns  of  danger  the  imminence 
of  which  is  announced  by  the  presence  of  flies,  and  to  provide 
them  with  proper  conditions  for  tranquil  sleep  in  properly 
sheltered  and  ventilated  places. 


1Y8  State  Department  of  Health 

There  is  great  need  for  intensive  education  of  mothers  and 
others  concerning  the  danger  frorii  the  common  cold,  the  impor- 
tance of  early  treatment  therefor,  and  the  necessity  of  preventing 
snch  infection  by  avoiding  contact  with  |x;rsons  having  even 
slight  colds. 

A  careful  analysis  of  the  causes  that  affect  the  lives  and  health 
of  children  shows  the  largest  factor  to  be  ignorance  on  the  part  of 
the  mother.  The  solution  of  the  infant  mortality  problem  lies  in 
the  education  of  the  mother  both  in  the  care  of  herself  and  her 
baby.  The  most  effective  method  of  combating  this  ignorance  is 
b}'  means  of  what  are  now  kno^\^l  as  child  welfare  stations.  The 
work  of  these  stations  is  preventive  and  the  aim  is  to  educate,  and 
not  to  treat  disease.  They  are  welfare  centers  for  well  babies, 
and  the  object  is  to  keep  them  well.  The  main  functions  of  a 
child  welfare  station  may  be  outlined  briefly  as  follows : 

To  advise  and  instruct  mothers  in  the  care  and  feeding  of 
babies ; 

To  encourage  and  prolong  breast  feeding ; 

When  artificial  feeding  is  necessary,  to  see  that  clean,  pas- 
teurized milk  is  provided,  to  prescribe  suitable  mixtures  and 
to  insure  the  proper  preparation  of  the  food  by  the  mothers 
in  their  own  homes ; 

To  teach  mothers  how  to  prevent  many  of  the  diseases  of 
childhood  due  to  exposure  and  errors  in  diet ; 

To  assist  in  the  care,  instruction  and  preparation  of  the 
expectant  mother; 

To  supervise  the  homes  and  surroundings  of  boarded  out 
children ; 

To  care  for  children  in  the  preschool  age ; 

To  maintain  a  place  where  mothers  will  come  with  their 
troubles  and  receive  sympathetic  and  intelligent  advice. 

The  child  welfare  nurse  is  the  most  important  factor  in  the 
success  and  usefulness  of  the  station.  She  must  have  tact,  per- 
severance and  the  genuine  art  of  leadership  among  mothers  and 
children. 

Some  of  her  duties  may  be  enumerated  as  follows: 

At  the  station  she  interviews  the  mothers  and  prepares  the 
babies  for  examination.     She  keeps  all  the  records  and  weighs 


Public  IIealtk  Xursing  179 

the  babies.  She  arranges  for  the  lectures  and  talks  and  gives 
practical  demonstrations.  At  the  homes  she  sees  that  the  instrac- 
tions  of  the  physician  ai-e  carried  out.  She  instructs  the  mothers 
in  their  own  homes  how  to  clothe,  care  for  and  feed  the  baby. 
When  the  physician  finds  defects  in  older  children,  such  as 
enlarged  tonsils,  adenoids,  decayed  teeth,  spinal  curvatures,  etc.,- 
the  nurse  goes  to  the  homes  and  sees  that  these  defects  are  remedied 
and  that  proper  hygienic  and  medical  treatment  is  given. 

Provisions  for  extending  relief  to  needy  cases  should  be  admin- 
istered by  the  nurse,  who  should  be  familiar  with  all  the  condi- 
tions. She  should  know  the  philanthropic  and  relief  agencies  of 
the  city  and  keep  in  touch  with  them.  She  should  have  tact  and 
delicacy  in  inducing  people  to  use  needed  public  and  private 
agencies  for  better  health  conservation.  The  nurse  should  have 
knowledge  of  the  care  of  pregnant  women  so  that  she  can  give 
advice  and  counsel.  The  nurse  should  visit  the  homes  and  urge 
mothers  to  attend  the  clinics  so  that  the  physician  may  make  exam- 
ination of  the  urine,  test  the  blood  pressure,  etc.  She  should 
instruct  the  mothers  in  the  hygiene  of  pregnancy  and  early  infancy, 
provide  for  confinement  in  a  hospital  or  at  home  by  a  physician, 
make  daily  visits  for  at  least  five  days  after  confinement  and  two 
visits  the  second  week  and  see  that  proper  prophylactic  treatment  is 
given  the  eyes  after  birth.  To  secure  early  prenatal  care  for  all 
prospective  mothers  it  is  essential  that  nurses  establish  friendly 
relations  with  all  local  midwives.  Most  of  these  women  are  amen- 
able to  friendliness.  If  they  learn  that  they  may  expect  good  faith 
from  the  nurse  they  will  in  many  instances  accept  her  instruction 
and  advice. 

The  nurse  should  arrange  to  be  at  the  station  at  a  stated  hour 
each  day  so  that  she  can  be  reached  by  the  mothers. 

In  the  absence  of  practical  instruction  of  girls  in  infant  care 
in  our  public  schools  the  public  health  nurse  should  be  competent 
to  furnish  this  instruction  in  classes  at  the  welfare  station.  This 
sort  of  instruction  is  now  quite  generally  incorporated  into  the 
syllabus  for  classes  in  household  arts  and  home  making. 

The  Board  of  Education  in  England  made  the  following  recom- 
mendations for  instruction  of  young  school  girls  in  infant  care 
and  management: 


180  State  Department  of  Health 

"  At  the  end  of  a  course  in  infant  care,  each  girl  when  she 
leaves  school  ought  to  know  how  to  wash  and  dress  a  baby ;  what 
clothes  it  should  wear  and  how  to  make  them;  the  advantage  of 
natural  over  artificial  food ;  how  much  cow's  milk  a  baby  requires 
and  how  exactly  its  '  bottle '  should  be  prepared  at,  say,  three, 
six  and  nine  months  of  age ;  how  to  feed  a  baby ;  how  to  prepare 
barley  water  and  whey ;  when  the  infant  may  first  have  solid  food, 
and  the  character  of  such  food;  why  patent  foods  should  not  be 
given;  what  are  the  signs  of  indigestion  (such  as  vomiting, 
diarrhea,  constipation  or  wasting),  and  why  it  is  important  to  pay 
attention  to  such  s^Txiptoms ;  how  much  sleep  is  required ;  how  to 
provide  a  comfortable  and  suitable  cradle;  why  fresh  air  and  sun- 
shine are  needful,  and  what  is  the  danger  from  draughts  and  cold; 
how  to  teach  a  baby  cleanly  and  desirable  habits ;  why  a  '  com- 
forter '  should  not  be  used ;  and  generally  how  the  hom-e  manage- 
ment should  be  undertaken. 

''  In  all  this  but  little  mention  need  be  made  of  disease  and 
illness.  It  is  not  desired  to  teach  every  school  girl  a  hotch-potch 
of  semi-medical  information  on  the  various  ailments  and  diseases 
to  which  infancy  is  liable,  but  to  give  her  a  simple  and  practical 
understanding  of  those  things  which  make  up  a  healthy  home  life 
for  little  children." 

The  child  welfare  nurse  should  have  a  working  knowledge  of 
food  values  and  dietetics  for  young  children.  She  should  be  com- 
petent to  outline  special  diets  and  to  demonstrate  in  the  mother's 
kitchen  how  the  foods  are  prepared.  She  should  know  the  faulty 
health  habits  that  produce  malnutrition  and  undernourishment. 

All  children,  both  in  the  preschool  and  the  school  period,  should 
be  weighed  at  least  once  a  month  and  measured  at  least  twice  a 
year.  The  ratio  between  the  height  and  weight  is  more  important 
in  determining  the  nutrition  of  the  child  than  in  comparing  the 
weight  and  age  as  is  usually  done.  The  following  table  ])repared 
by  Dr.  Thomas  Wood  is  recommended  by  the  Child  Health  Organ- 
ization. If  a  child  weighs  seven  per  cent  less  than  the  average 
for  its  height  it  should  be  considered  undernourished.  Over- 
nourishment  to  the  extent  of  15  per  cent  over  the  average  should 
be  considered  abnormal  and  be  remedied  by  suitable  diet,  exer- 
cise and  health  habits. 


Public  Health  Nursing 


181 


EIGHT  HEIGHT  AND  WEIGHT  FOR  GIRLS 


Height 
inches. 

5 

yrs. 

6 

yrs. 

7 
yrs. 

8 
yrs. 

9 

yrs. 

10 
yrs. 

11 

yrs. 

12 
yrs. 

13 

yrs. 

14 
yrs. 

15 
yrs. 

16 

yrs. 

y'l 

18 
yrs. 

39 

40 

41 

42 

43 

44 

45 

46 

47 

34 

36 

40 
42 
44 
46 

48 

35 
37 
39 
41 
42 
45 
47 
48 
49 
51 
53 

36 
38 
40 
42 
43 
45 
47 
49 
50 
52 
54 
56 
59 
62 

43 
44 
46 
48 
50 
51 
53 
55 
57 
60 
63 
66 
68 

49 
51 
52 
54 
56 
58 
61 
64 
67 
69 
72 
76 

53 
55 
57 
59 
62 
65 
68 
70 
73 
77 
81 
85 
89 

56 
58 
60 
63 
66 
68 
71 
74 
78 
82 

90 
94 
99 
104 
109 

61 
64 
67 
69 
72 
75 
79 
83 
87 
91 
95 
101 
106 

115 
117 
119 

70 
73 
76 
80 
84 
88 
93 
97 
102 
107 
112 
117 
119 
121 
124 
126 
129 

77 
81 
85 
89 
94 

104 
109 
113 
118 
120 
122 
126 
128 
131 
134 
138 

86 
90 
95 
100 
106 
111 
115 
119 
122 
124 
127 
130 
133 
136 
140 
145 

91 
96 
102 
108 
113 
117 
120 
123 
126 
128 
132 
135 
138 
142 
147 

98 
104 
109 
114 
118 
121 
124 
127 
129 
133 
136 
139 
143 
148 

48 

49 

50 

53 

54 

56 

57 

58 

59 .  .  .   . 



60 

106 

61 

HI 

62 

115 

63.  . 

119 

64 

122 

65 

125 

66  . 

128 

67 

130 

134 

69 

137 

70 

140 

71 

144 

72 

149 

PREPARED  BY  DR.   THOMAS   D.   WOOD. 


About  what  a  girl  should  gain  each  month. 

AGE  AGE 

5  to    8 6  oz.  14  to  16 : 8  o«. 

8  to  11 8  oz.  16  to  18 4  oi, 

H  to  14 12  oz. 

Weights  and  measures  should  be  taken  withDUt  shoes  anJ  In  only  th2  U3ual  indoor  clothes. 


182 


State  Depaktment  of  Health 


RIGHT  HEIGHT  AND  WEIGHT  FOR  BOYS 


Height 
inches. 

5 

yrs. 

6 

yrs. 

7 
yrs. 

8 
yrs. 

9 
yrs. 

10 

yrs. 

11 

yrs. 

12 
yrs. 

13 
yrs. 

14 
yrs. 

15 
yrs. 

16 
yrs. 

17 
yrs. 

18 
yrs. 

39 

40 

41 

42 

43 

44 

45 

46 

47 

35 
37 
39 
41 
43 
45 
47 
48 

36 

40 
42 
44 
46 
47 
49 
51 
53 
55 

37 
39 

41 
43 
45 
46 
48 
50 
52 
54 
56 
58 
60 
62 

44 
46 
47 
48 
50 
52 
55 
57 
59 
61 
63 
66 
69 

49 

51 
53 
55 
58 
60 
62 
64 
67 
70 
73 
77 

54 
56 
58 
60 
63 
65 
68 
71 
74 
78 
81 
84 
87 
91 

57 
59 
61 
64 
67 

72 
75 
79 
82 
85 
88 
92 
95 
100 
105 

62 
65 

11 

73 
76 
80 
83 
86 
89 
93 
97 
102 
107 
113 

74 
77 
81 
84 
87 
90 
94 
99 
104 
109 
115 
120 
125 
130 
134 
138 

78 
82 
85 
88 
92 
97 
102 
106 
111 
117 
122 
126 
131 
135 
139 
142 
147 
152 
157 
162 

86 
90 
94 
99 
104 
109 
114 
118 
123 
127 
132 
136 
140 
144 
149 
154 
159 
164 
169 
174 

91 
96 
101 
106 
111 
115 
119 
124 
128 
133 
137 
141 
145 
150 
155 
160 
165 
170 
175 

97 
102 
108 
113 
117 
120 
125 
129 
134 
138 
142 
146 
151 
156 
161 
106 
171 
176 

48 

49 

60 

51 

52 

53  . 

54 

55 

57 

58 

60 

61 

110 

62 

116 

63 

119 

64 

122 

65 

126 

66 

130 

67 

135 

68 

139 

143 

70 

147 

71 

152 

157 

73 

162 

74 

167 

76   .  . 

172 

76 

177 

PREPAEKD  BY  DR.   THOMAS   D.   WOOD. 

About  what  a  boy  should  gain  each  month. 

AQE 


AOB 

5  to    8. 
8  to  12. 


6  oz. 
8  oi. 


12  to  16. 
16  to  18. 


Weigh  on  the  same  date  each  month  about  the  same  hour  of  the  day. 


Public  Health  Nuksing  1S3 

Health  supervision  and  education  of  the  school  child  in  the  State 
of  New  York  is  definitely  assigned  through  legislative  enactment 
to  the  State  Department  of  Education.  Yet  school  children  are 
for  the  major  part  of  their  time  outside  of  school  control  and  in 
many  conununities  health  work  in  the  schools  is  undergoing 
very  slow  growth.  It  is  therefore  important  that  every  public 
health  nurse,  especially  those  engaged  in  child  welfare,  should 
consider  the  life  of  the  child  in  its  entirety.  For  this  reason  the 
following  minimum  standards  for  the  school  and  the  adolescent 
child,  which,  with  those  previously  quoted,  comprise  those  estab- 
lished by  the  Children's  Bureau,  are  here  inserted. 

"Minimum   Standards   in   Child  Welfare   for   School 
Children 

1  Proper  location,  construction,  hygiene,  ventilation,  and  sani- 

tation of  schoolhouse ;  adequate  room  space  —  no  overcrowd- 
ing. 

2  Adequate    playground    and    recreational    facilities',    physical 

training,  and  supervised  recreation. 

3  Adequate  space  and  equipment  for  school  medical  work  and 

available  laboratory  service.  . 

4  Full-time  school  nurse  to  give  instruction  in  personal  hygiene 

and  diet,  to  make  home  visits  to  advise  and  instruct  mothers 
in  principles  of  hygiene  and  nutrition  and  to  take  children 
to  clinics  with  permission  of  parents. 

5  Part-time  physician  with  one  full-time  nurse  for  not  more 

than  2,000  children;  if  physician  is  not  available,  one  school 
nurse  for  every  1,000  children ;  or  full-time  physician  with 
two  full-time  nurses  for  4,000  children  for: 

(a)  Complete    standardized    basic    physical    examinations 

once  a  year,  with  determination  of  weight  and  height 
at  beginning  and  end  of  each  school  year;  monthly 
weighing  wherever  possible. 

(b)  Continuous  health  record  for  each  child  to  be  kept  on 

file  with  other  records  of  the  pupil.  This  should 
be  a  continuation  of  the  preschool  health  record 
which  should  accompany  the  child  to  school. 

(c)  Special  examinations  to  be  made  of  children  referred 

by  teacher  or  nurse. 

(d)  Supervision  to  control  communicable  disease. 

(e)  Kecommendation  of  treatment  for  all  remediable  de- 

fects, diseases,  deformities,  and  cases  of  malnutri- 
tion. 


184  State  Department  of  Health 

''(f)   Follow-up  work  by  nurse  to  see  that  physician's  recom- 
meudutions  are  carried  out. 

G  Available  clinics  for  dentistry,  nose,  throat,  eye,  ear,  skin, 
and  orthopedic  work ;  and  for  free  vaccination  against  small- 
pox. 

7  Open-air  classes  with  rest  periods  and  supplementary  feedings 

for  pretuberculars  and  certain  tuberculous  children,  and 
children  with  grave  malnutrition.  Special  classes  for 
children  needing  some  form  of  special  instruction  due  to 
physical  or  mental  defect. 

8  Nutrition  classes  for  physically  subnormal  children,  and  the 

maintenance  of  midmorning  lunch  or  hot  noonday  meal 
when  necessary. 

9  Examinations  by  psychiatrist  of  all  atypical  or  retarded  chil- 

dren. 

10  Education  of  school  child  in  health  habits,  including  hygiene 

and  care  of  young  children. 

11  General  educational  work  in  health  and  hygiene,   including 

education  of  parent  and  teacher,  to  secure  full  cooperation 
in  health  program. 

"Adolescent  Children 

1  Complete  standardized  basic  physical  examination  by  physi- 

cian, including  weight  and  height,  at  least  once  a  year,  and 
recommendation  for  necessary  treatment  to  be  given  at 
children's  health  center,  school,  or  other  available  agency. 

2  Clinics  for  treatment  for  defect  and  disease. 

3  Supervision  and  instruction  to  insure : 

(a)  Ample  diet,  with  special  attention  to  growth-produc- 

ing foods. 

(b)  Sufficient  sleep  and  rest  and  fresh  air. 

(c)  Adequate  and  suitable  clothing. 

(d)  Proper  exercise  for  physical  development. 

(e)  Knowledge  of  sex  hygiene  and  reproduction. 

4  Full  time  education  compulsory  to  at  least  16  years  of  age, 

adapted  to  meet  the  needs  and  interest  of  the  adolescent 
mind,  with  vocational  guidance  and  training. 

5  Clean,  ample  recreational  opportunities  to  meet  social  needs, 

with  supervision  of  commercial  amusements. 

6  Legal  protection  from  exploitation,  vice,  drug  habits,  etc." 


Public  Health  IsTuksing  185 

CHAPTER    XV 
Supervision  of  Midlives 

The  following  laws  and  regulations  govern  the  practice  of  mid- 
wifery in  the  State  of  New  York : 

Chapter  559,  Laius  of  1913.  (§  2-b  Sanitary  Code) :—  The 
public  health  council  shall  have  power  by  the  affirmative  vote  of  a 
majority  of  its  members  to  establish  and  from  time  to  time  amend 
sanitary  regulations,  hereinafter  called  the  sanitary  code,  without 
discrimination  against  any  licensed  physicians.  The  sanitary  code 
may  deal  with  any  matters  affecting  the  security  of  life  or  health 
or  the  preservation  and  improvement  of  public  health  in  the  state 
of  New  York,  and  with  any  matters  as  to  which  jurisdiction  is 
hereinafter  conferred  upon  the  public  health  council.  The  sani- 
tary code  may  include  provisions  regulating  the  practice  of 
midwifery. 

These  regTdations  are  found  in  chapter  IV  of  the  sanitary  code 
a  copy  of  which  may  be  obtained  by  applying  to  the  State  Depart- 
ment of  Health,  Albany,  N".  Y. 

The  Penal  Law,  Section  482,  Paragraphs  3  and  4  contain  the 
following : 

A  peison  who:  (3.) — Being  a  midwife,  nurse  or  other  person 
having  the  care  of  an  infant  within  the  age  of  two  weeks  neglects 
or  omits  to  report  immediately  to  the  health  officer  or  to  a  legally 
qualified  practitioner  of  medicine  of  the  city,  town  or  place  where 
such  child  is  being  cared  for,  the  fact  that  one  or  both  eyes  of  such 
infant  are  inflamed  or  reddened  whenever  such  shall  be  the  case, 
or  who  applies  any  remedy  therefor  without  the  advice,  or  except 
by  the  direction  of  such  officer  or  physician;  or,  (4.) — neglects, 
refuses  or  omits  to  comply  with  any  provisions  of  this  section, 
...    is  guilty  of  a  misdemeanor. 

What  the  Midwife  Must  Do  to  Peactice 
She  must : 

1  Secure  her  license  to  practice  from  the  State  Department  of 
Health,  the  license  to  be  renewed  on  January  first  annually ; 

2  Register  annually  her  name  with  the  local  registrar  of  vital 
statistics  in  each  municipality  in  which  she  desires  to  practice ; 


186  State  Depaetment  op  Health 

3  File  birth  certificates  within  five  days  after  birth  with  the 
local  registrar  of  vital  statistics  of  the  place  in  which  birth  occurs ; 

4.  If  a  child  does  not  breathe  after  birth  (stillbirth),  leave  the 
birth  certificate  at  the  house  and  at  once  report  the  case  by  tele- 
phone, messenger,  or  in  person,  to  the  health  officer.  He  will 
personally  investigate,  or  send  an  inspector  to  do  so,  and  will 
countersign  the  birth  certificate  and  file  it  with  the  registrar.  A 
midwife  can  not  sign  the  death  certificate  for  a  stillborn  child  — 
this  must  be  done  by  the  health  officer,  or  by  a  coroner  or  similar 
public  officer  if  an  inquest  on  the  body  is  necessary,  as  provided 
by  section  378  of  the  Vital  Statistics  Law; 

5  Secure  from  the  local  health  officer  and  keep  on  hand  a  suf- 
ficient supply  of  ophthalmia  neonatorum  outfits  and  make  use  of 
these  according  to  directions,  in  every  case; 

6  Keep  a  record  of  births  reported  by  her  on  the  stub  of  her 
record ; 

7  Comply  in  every  respect  with  the  rules  and  regulations 
governing  the  practice  of  midwifery. 

Penalties 

The  penalty  for  violation  of  regulations  of  the  Sanitarv^  Code 
(Chapter  1,  Regulation  2)  is: 

Any  violation  of  any  provision  of  this  code  is  hereby  declared 
to  be  a  misdemeanor  and  is  punishable  by  a  fine  of  not  more  than 
fifty  dollars  or  by  imprisonment  for  not  more  than  six  months, 
or  by  both. 

The  penalty  for  violation  of  health  laws,  (Section  1740,  para- 
graph 2,  Penal  Law)  is: 

A  person  who  wilfully  violates  any  provision  of  the  health  laws, 
or  any  regulation  lawfully  made  or  established  by  any  public 
officer  or  board  under  authority  of  the  health  laws  the  punishment 
for  violating  which  is  not  otherwise  prescribed  by  those  laws,  or 
by  tliis  chapter,  is  punishable  by  imprisonment  not  exceeding  one 
year,  or  by  a  fine  not  exceeding  two  thousand  dollars  or  by  both. 

The  penalty  for  failure  to  report  a  birth  in  accordance  with 
the  requirements  of  the  Vital  Statistics'  Law  (Par.  392,  Vital 
Statistics  Law)  is: 


Public  Health  Is^ursing  18T 

u  *  *  *  Whenever  any  physician,  midwife,  or  other  person 
shall  fail  or  neglect  to  properly  record  and  file  a  certificate  of  birth 
as  required  by  this  article,  such  person  shall  be  liable  to  a  penalt;y 
of  not  less  than  five  dollars  nor  more  than  fifty  dollars  for  the 
first  and  second  ofi'enses,  which  penalty  may  be  recovered  by  an 
action  brought  by  the  state  commissioner  of  health  in  any  court 
of  competent  jurisdiction,  and  for  every  subsequent  offense,  such 
person  shall  be  guilty  of  a  misdemeanor,  punishable  by  a  fine  of 
not  less  than  ten  nor  more  than  one  hundred  dollars,  or  by  impris- 
onment for  not  more  than  sixty  days,  or  both." 

Directions  for  the  Inspection  of  Midwives 

1  Visit  each  midwife  at  the  address  given  upon  the  list  fur- 
nished you.  In  case  the  midwife  is  out  you  should  visit  and 
revisit  until  she  is  found.  If  she  has  moved  to  a  new  address 
you  should  go  to  the  new  address.  Ask  the  midwife  to  show  her 
license,  and  see  that  the  name  and  address  correspond.  If  a 
midwife  is  married  report  to  the  Department  of  Health  if  the 
license  does  not  contain  her  married  name. 

2  See  that  the  midwife's  sign  corresponds  with  the  name  upon 
the  license,  and  that  there  is  no  misleading  information  on  her 
sign,  card,  advertisement,  or  any  handbill.  Copies  of  the  three 
latter  should  be  obtained. 

3  Remember  that  the  license  is  for  one  year  only,  and  if  it 
is  to  expire  within  a  short  time  notify  the  midwife  that  she  must 
obtain  a  new  license  from  the  State  Department  of  Health. 

4  Note  the  general  character  of  the  house  in  which  the  midwife 
lives.  Note  also  the  general  condition  of  the  home  as  to  neatness 
and  cleanliness. 

5  Note  the  condition  of  the  midwife's  person  —  her  clothing, 
hands  and  fingernails.  The  clothing  should  be  neat  and  clean, 
and  the  hands  and  fingernails  clean,  smooth  and  short. 

6  Examine  the  stubs  of  the  midwife's  records  of  births,  and 
note  whether  or  not  they  are  properly  kept  and  legible.  Ascertain 
whether  or  not  the  midwife  can  read  and  understand  a  paragraph 
of  the  regulations,  and  whether  she  can  fully  fill  out  a  birth 
certificate  in  her  own  handwriting. 


188  State  Department  of  Health 

7  Inspect  the  equipment,  and  see  if  the  following  articles  are 
in  the  midwife's  bag : 

Nail  brush 

Wooden  or  bone  nail  cleaner 

Jar  of  green  or  soft  castile  soap 

Tube  of  vaseline 

Clinical  thermometer 

Agate  or  glass  douche  reservoir 

Two  rounded  vaginal  douche  nozzles  (not  to  be  used  except 
upon  physician's  order) 

Two  rectal  nozzles,  large  and  small 

One  soft  rubber  catheter 

Blunt  scissors  for  cutting  cord 

Lysol 

Boric  acid  powder 

Medicine  dropper 

Narrow  tape  or  soft  twine  for  tying  cord 

Sterile  absorbent  cotton  (preferably  in  1/4  1^-  packages) 

Silver  nitrate  outfits  furnished  by  the  State  Department  of 
Health  free  of  charge. 

Each  and  every  article  should  be  inspected  and  opposite  this 
list  you  should  write  "G"  or  "B"  and  "C"  or  "  D  ",  for 
"Good"  and  "-Bad",  "Clean"  or  "Dirty". 

8  Note  the  condition  of  the  bag,  whether  or  not  it  contains  a 
washable  lining  or  metal  case;  whether  it  is  in  good  or  bad  con- 
dition, clean  or  dirty, 

9  Ascertain  whether  the  midwife  has  in  her  possession  any 
instruments,  and  inquire  particularly  as  to  the  following: 

Speculum 
Dressing  forceps 
Uterine  dressing  forceps 
Obstetrical  forceps 
Uterine  sound  or  applicator 
Hypodermic  syringe 
Artery  clamps 
Uterine  irrigators 
Wire  catheters 
Uterine  syringes 
Any  other  instrument. 


Public  Health  Nursing  189 

In  case  you  have  any  suspicion,  asik  to  be  shown  any  cupboards 
or  closets  where  ®uch  instruments  could  be  concealed. 

Ask  the  midwife  to  surrender  any  instrument  and  state  that  if 
any  are  found  on  subsequent  visits  you  will  recommend  cancelling 
her  license, 

10  Note  whether  or  not  the  midwife  has  an  examining  chair  or 
table  which  might  be  used  for  either  operations  or  treatments'. 

11  Ascertain  whether  the  midwife  has  any  drugs  in  her  posses- 
sion, other  than  the  disinfectant  required  for  her  practice,  and 
whether  or  not  she  has  a  medicine  case  or  cabinet.  Do  not  include 
personal  household  remedies  or  cosmetics. 

12  Note  whether  the  midwife  has  a  sufficient  supply  of 
ophthalmia  neonatorum  outfits.  If  she  has  not,  she  should  be 
advised  that  she  can  get  them  from  the  local  health  officer. 

The  midwdfe  should  have  in  her  possession  a  copy  of  Rules  and 
Regulations  for  Midwives. 

13  Note  whether  there  are  accommodations  for  the  delivery  of 
women  at  the  midwife's  home.  Their  presence  should  arouse  sus- 
picion that  the  midwife  might  possibly  be  inducing  abortions  or 
labor  and  delivering  women  who  desire  secrecy. 

14  In  using  the  form  for  the  inspection  of  midwives  report 
as  below  under  each  heading. 

(a)  If  license  sign  and  name  are  correct,  mark  0.  K.,  if 
incorrect,  state  "  Inc,"  and  notify  the  Albany  office. 

(b)  Note,  with  letters  "G"  or  "  B  ",  if  good  or  bad; 
"  C  "  or  "  D  ",  if  clean  or  dirty. 

(c)  Note  '' P  "  or  "A"  for  present  or  absent;  "W"  or 
"  NW  "  for  washable  or  nonwashable. 

(d)  Inspect  record  of  births,  and  if  any  are  not  recorded 
see  that  local  registrar  receives  the  report;  and  advise  mid- 
wife that  such  an  oversight  is  a  violation  of  the  law,  and 
report  to  the  Director  of  the  Division  of  Vital  Statistics. 

(e)  Note  number  of  cases  attended. 

(f )  Note  whether  or  not  physician  was  called,  and  if  so 
for  what  reason. 

(g)  Inquire  as  to  the  general  health  of  the  midwife  and 
her  family.     Also  inquire  whether  or  not  there  has  been  anj 


190  State  Depaetmekt  of  Health 

communicable  disease  in  the  home.  Give  instructions  as  to 
precautions  to  be  taken  in  a  case  of  communicable  disease. 
(See  Eules  and  Regulations  for  Midwives  issued  by  State 
Department  of  Health.) 

(h)  State  whether  wholly  self-supporting  or  partly  self- 
supporting  and  state  what  other  work,  if  any. 

(i)  Report  the  presence  or  absence  of  instruments.  See 
Rule  Xo.  9. 

(j)  Report  whether  any  additional  beds  are  present.  See 
Rule  13. 

15.  On  inspection  form  (page  2),  cheek  list  of  equipment  and 
note  condition  "  G  "  or  "  B  "  and  note  instruments  found,  if  any. 

16  Each  form  must  be  made  in  duplicate  and  one  sent  to  the 
Albany  office  and  one  retained  by  the  nurse. 

17  Visit  each  midwife  during  the  thirty  days  previous  to  the 
expiration  of  her  license  and  write  to  the  Albany  office  whether 
or  not  you  reconmiend  the  renewal  of  her  license,  stating  why. 
If  operating  under  an  old  license  such  license  should  be  taken  and 
mailed  to  the  Albany  office. 

18  Visit  the  office  of  the  local  registrar  and  ask  whether  each 
midwife  on  your  list  is  duly  registered  in  his  office  as  required 
by  law.  Ask  also  if  he  knows  of  any  midwives  not  licensed  but 
practicing;  whether  any  midwife  is  late  in  filing  certificates  of 
birth,  and  any  other  information  which  he  happens  to  have  in 
regard  to  any  individual  midwife.  See  that  unlicensed  women  are 
not  registered. 

19  Inquire  of  each  midwife  if  she  knows  of  any  other  women 
practicing  in  her  neighborhood  and  visit  any  whom  you  think 
may  be  practicing  without  a  license. 

20  If  these  directions  are  lost  or  mislaid  or  new  forms  are 
needed  apply  at  the  Albany  office. 

When  births  are  discovered  that  are  apparently  or  possibly 
unreported  fill  out  a  blank  certificate  of  birth  and  have  it  signed 
by  the  parent,  or  if  the  parent  is  illiterate  the  parent  should  make 
his  or  her  mark,  the  nurse  signing  as  witness. 

The  nurse  should  examine  the  register  kept  by  the  local  regis- 
trar of  vital  statistics  to  see  if  the  birth  has  been  reported.  If 
unreported  she  should  file  her  certificate  with  the  registrar.     If 


Public  Health  Nursing  191 

the  child  was  born  in  another  municipality,  not  visited  by  the 
nurse,  the  certificate  should  be  mailed  by  the  nurse  to  the  registrar 
of  the  municipality  in  which  the  child  was  born  with  a  statement 
of  facts.  If  the  nurse  can  not  readily  secure  the  name  of  the  regis- 
trar of  the  other  municipality,  she  should  forward  it  addressed 

to  ''  Registrar  of  Town  (or  Village  or  City)  of ". 

Blank  certificates  for  birth  reports  are  supplied  by  the  State 
Department  of  Health  to  all  local  registrars  from  whom  they  may 
be  secured  as  needed. 

When  a  nurse  finds  a  woman  practicing  who  apparently  is 
unlicensed,  or  who  can  not  show  her  license  she  should  notify  the 
State  Department  of  Health  giving  the  name  and  address  of  such 
woman. 


]92  State  Department  of  Healti 


CHAPTER    XVI 
Health  Supervision  of  the  School  Child 

Health  feupei-vision  of  the  school  child  has  been  the  logical  result 
of  compulsory  public  education.  The  State  provides  the  equip- 
ment for  education  and  compels  the  child  to  utilize  it.  To  assem- 
ble the  state's  children  in  the  various  school  houses  was  the  surest 
way  to  discover  defects  from  heredity  and  environment  in  the 
individual.  To  attempt  to  determine  clearly  the  nature  of  these 
defects  and  to  correct  such  as  were  remediable  was  an  inevitable 
result,  necessitating  for  its  accomplishment  a  more  intimate  rela- 
tion between  those  who  control  the  child  in  school  and  those  who 
are  responsible  for  him  out  of  school.  It  has  long  been  recog- 
nized that  certain  defects  increase  during  school  years,  and  may 
be  classed  as  occupational.  Obviously  the  school  should  prevent 
the  development  of  these  defects.  A  high  educational  authority 
has  said  that  871/^  per  cent  of  all  education  is  physical. 

The  value  of  the  nurse's  service  in  the  community  will  depend 
on  her  ability  to  secure  coi-rection  of  insanitary  conditions  in  the 
home  as  well  as  in  the  school  room.  There  has  becu  considerable 
discussion  as  to  whether  the  school  nurse  should  be  assigned  to  the 
routine  examination  of  children  for  physical  defects  and  to  class- 
room inspection  to  discover  communicable  disease.  Local  condi- 
tions, expediency  and  the  qualifications  of  the  individual  nurse  are 
bound  to  be  deciding  factors  in  most  schools.  No  thinking  person 
can  doubt  that  a  nurse  technically  well  trained  can  discover  when 
vision  or  hearing  is  not  normal,  when  speech  defects  exist,  when 
there  is  nervous  disturbance,  and  when  there  are  symptoms  of 
infectious  disease  which  call  for  exclusion  from  the  classroom, 
and  that  she  can  properly  record  subsequent  observations  of  such 
cases.*  But  the  decision  of  which  is  the  cause  of  the  trouble  must 
rest  with  the  physician.  It  will  often  take  both  physician  and 
nurse  to  detennine  the  nature  and  cause  of  an  existing  disturb- 
ance and  to  secure  its  correction. 


*  It  is  also  undonbti'dly   true  that  Icaclu'ra   can   he  so   trained   in   normal 
seliools  that  they  may  Katisfaetorily  pertorni  siuh  usual  elassroom  i!-speetion. 


Public  Health  Nursing  193 

The  interest  of  school  authorities,  teachers,  parents,  and  the  gen- 
eral public  must  frequently  be  enlisted  before  certain  children  will 
have  been  provided  with  the  fundamental  essentials  for  a  healthful 
life  and  good  citizenship.  The  provision  for  school  instruction 
in  the  open  air  is  one  instance  where  community  interest  has  had 
to  be  aroused  and  guided  to  insure  to  certain  children  a  chance 
to  live.  Thus  far  this  community  interest  has  been  largely  con- 
lined  to  urban  schools.  To  secure  rural  community  action,  to 
transform  conditions  in  the  one  room  rural  school  so  that  it 
will  be  comparable  to  an  open  air  school  is  an  urgent  and 
vital  need  in  the  solution  of  which  the  public  health  nurse  will 
have  the  opportunity  for  all  the  service  and  cooperative  work  of 
which  she  is  capable.  When  the  work  is  accomplished  the  children 
will  not  only  be  studying  in  the  open  air,  but  they  will  be  warmly 
and  suitably  clothed,  wisely  and  abundantly  fed,  as  clean  in  body 
and  clothing  as  soap,  water  and  a  will  to  be  clean  can  make  them, 
and  they  will  be  getting  ten  hours  sleep  out  of  each  twenty-four. 

Physical  Defects  in  the  Child 
The  following  tables  indicate  the  physical  condition  of  school 

children  as  shown  in  several  communities. 

In  a  recent  examination  of  newly  admitted  school  children  in 

the  City  of  New  York  5,780  cases  were  examined  by  the  school 

physicians  and  5,940  by  private  physicians. 

The  percentage  of  defects  found  were  as  follows: 

Examination  by    Examination  by 
School  Medical  Private 

Inspectors  Physicians  * 

Defective  vision    7 .                                     4 . 

Defective  hearing  .38                                   .77 

Defective  teeth  71.2  36.5 

Defective  nasal  breathing 12.3  12.2 

Hypertrophied  tonsils   13.1  21.8 

Malnutrition 6.3  12.9 

Cardiac  disease   1.1                                  2.1 

Pulmonary  disease   .81                                  1.9 

Orthopedic  defects    1.1                                    1-7 

Nervous  diseases   .91                                3.9 


Dr.  Haven  Emerson,  New  York  State  Journal  of  Medicine,  May,  1916. 

7 


194  State  Department  of  Health 

It  is  interesting  to  note  that  in  ^ew  York  City  16  per  cent  of 
the  children's  parents  employed  a  private  physician.  The  extra 
expense  of  including  these  children  in  the  medical  examination 
by  the  health  department  physicians  and  nurses  would  have  been 
39  cents  per  capita.* 

An  inspection  of  children  in  the  rural  schools  of  Pennsylvania 
in  districts  with  population  of  less  than  5,000  made  by  the 
Pennsylvania  State  Department  of  Health  gave  results  as 
follows  :f 

Number  of  children  inspected 17,697 

Defective  teeth    53 . 7% 

Dirty  teeth   8.4% 

Gums  diseased   45 . 3% 

Tonsils  enlarged   26 . 3% 

Adenoids 34 . 8% 

Enlarged  cervical  glands 4 . 9% 

Goitre 4.9% 

Defective  vision   17 . 8% 

Other  eye  affections 3.1% 

Malnutrition 48 . 7% 

Tuberculosis 4 . 4% 

Head  lice   27 . 5% 

Other  skin  diseases 8 .    % 

Deformities  —  spinal  curvature   1 .    % 

Other  deformities   9 . 3% 

Defective  hearing   3 . 3% 

Defective  breathing 4 . 9% 


Concerning  the  presence  of  multiple  defects  in  children  of  rural 
districts  and  the  results  in  treatment  through  advising  the  parent 
or  guardian  by  letter,  Dr.  Samuel  G.  Dixon  in  the  article  to 
which  reference  has  already  been  made,  gives  the  following  inter- 
esting figures : 

Total  number  of  pupils  inspected 469,199 

Defective 335,427 

Not  defective  133,772 

Single  defects  in 184,900 

Multiple  defects  in 150,527 

Total  defects 551,671 

Pupils'  treatment  advised  by  letter  to  parent  or  guardian 304,019 

Pupils'  reported  treated    ( 18%  of  notifications) 64,941 

Pupils'  improved  by  treatment  (95%  of  those  treated) 52.406 

*  Weekly  Bulletin  of  the  Department  of  Health,  Citv  of  New  York.  June  24, 
1916. 

t  Some  results  of  the  Health  Inspections  of  Four  Hundretl  Tliousand 
Rural  School  Children  in  Pennsylvania  —  Samuel  G.  Dixon,  Commissioner  of 
Health,  Pennsylvajnia. 


Public  Health  Nursing  195 

From  the  foregoing  records  the  nurse  is  justified  in  concluding 
that: 

(a)  approximately  50  per  cent  of  all  children  on  their  first 
admission  to  school  are  in  need  of  immediate  attention  for 
throat  and  mouth  or  eye  defects; 

(b)  a  good  percentage  of  the  defects  will  he  remedied 
to  the  improvement  of  the  health  of  the  child  if  the  parent 
or  guardian  is  notified  in  writing ; 

(c)  in  notifying  the  parent  or  guardian  it  is  desirable 
to  enclose  literature  designed  to  teach  adults  the  importance 
of  oral  hygiene,  and  the  necessity  for  accurate  correction  of 
defects  of  vision; 

(d)  provision  should  be  made  for  the  correction  of  the 
defects  of  children  whose  parents  do  not  provide  the  treat- 
ment necessary  after  notification; 

(e)  the  public  health  nurse  is  the  best  agent  for  accom- 
plishing the  greatest  results; 

(f )  when  multiple  defects  exists,  record  should  be  made  of 
mental,  nutritional  and  general  physical  improvement  fol- 
lowing treatment  of  oral  and  vision  defects  in  order  to  fur- 
nish data  for  further  study  and  conclusions. 

Methods  for  Securing  Correction  of  Defects  When  Par- 
ents Do  ISTot  or  Can  Not  Attend  to  the  Matter 

Whenever  after  a  reasonable  time  any  child  has  not  had  treat- 
ment for  the  defective  condition,  the  nurse  should  visit  the  home 
to  urge  the  importance  of  such  corrective  treatment.  Sometimes 
six  and  eight  visits  of  this  nature  must  be  made  before  the  parents 
sufficiently  appreciate  the  situation  to  consult  a  private  phy- 
sician or  consent  to  pay  for  treatment  when  provided  at 
cost.  For  children  in  rural  districts  an  arrangement  may  some- 
times be  made  with  local  physicians  or  dentists  for  a  day  when 
all  cases  may  receive  operative  or  other  treatment  at  cost,  or  with- 
out cost  for  any  who  should  have  it  so  provided.  In  some  instances 
a  date  is  arranged  in  some  neighboring  city  and  a  group  of  chil- 
dren is  taken  to  a  hospital  or  dispensary  for  operation.  Mobile 
eye  and  dental  dispensaries  are  now  being  operated  in  some  parts 


196  State  Department  of  Health 

of  New  York  State  for  the  benefit  of  rural  children.  Under  adult 
stimulation  the  children  themselves  frequently  organize  remedial 
measures  as  valuable  for  educational  as  for  corrective  ends,  as  for 
example,  the  Nassau  County  Junior  Ked  Cross  Dental  Clinic. 

A  progressive  superintendent  of  schools  in  a  rural  village  of 
New  York  State  arranged  to  have  medical  and  surgical  service 
brought  from  a  neighboring  city  on  certain  days.  On  these  days 
the  teachers,  local  nurses  and  citizens  assisted  at  a  com- 
munity session  for  dispensary  and  clinic  ser\'ice.  In  the  library 
of  the  school  cots  w^ere  placed,  while  the  superintendent's  office 
was  the  (jperating  room,  the  school  nurse  managing  the  nursing 
side  of  the  function.  The  domestic  science  class  washed  the 
towels  and  helped  in  the  general  clean-up.  With  a  little  enter- 
prise and  enthusiasm  this  community  work  may  be  developed  in 
any  rural  district.  A  well  written  newspaper  account  of  how 
it  was  done  inspires  other  neighborhoods. 

The  two  factors  which  the  nurse  will  find  necessary  for  the 
accomplishment  of  this  corrective  work  are  the  recognition  that  it 
is  needed  and  the  development  of  a  desire  on  the  part  of  the  people 
to  provide  it.  The  cost  of  the  work  under  such  community  initia- 
tive will  be  reduced  to  a  minimum,  and  will  come  within  the 
means  of  a  large  proportion  of  both  native  and  foreign  born 
parents.  The  nurse  should  know  the  number  and  the  nature  of 
her  cases,  and  she  should  find  out  the  comparative  cost  in  time 
and  money  of  taking  the  children  to  another  place,  and  of  bring- 
ing the  treatment  to  the  children.  The  preferences  of  local  phy- 
sicians and  dentists  should  be  considered  before  any  decision  is 
reached. 

Some  Eesults  to  Health  From  the  Continued  Presence  of 
Physical  Defects 
From  Decaying  Teeth  and  Diseased  Gmns  and  Tonsils 
Oral  sepsis  as  a  factor   in  general  systemic  disturbance  has 
for  some  time  been  generally  recognized.     That  decaying  teeth  — 
even  those  of  the  temporary  set  —  may  result  in  disease  of  the 
tonsils,  middle  ear,  and  glands  of  the  neck  has  been  long  recog- 
nized; more  recent  is  the  knowledge  that  arthritis,  endocarditis, 
deafness,  functional  heart  disturbance,  mastoid  disease,  asthma. 


Public  Health  ISTuksing  197 

goitre,  frequent  sore  throat,  neuritis,  appendicitis  and  cholecystitis 
often  are  caused  by  a  septic  focus  in  one  or  more  teeth,  or 
from  diseased  tonsils.  Insanitary  fillings,  insanitary  crowns  and 
other  forms'  of  dentistry  have  resulted  in  as  much  general  dis- 
turbance as  have  totally  neglected  teeth.  Diseased  tonsils  and 
dental  caries  may  produce  conditions  favorable  for  infection  with 
communicable  disease,  including  tuberculosis. 

Adenoids  and  eye  defects  are  the  cause  of  much  backwardness 
in  mental  development,  of  faulty  posture  and  of  general  nutritional 
disturbance. 

Deafness,  anemia,  nutritional  disturbances,  mental  sluggish- 
ness, glandular  swelling  and  spinal  curvature  are  frequently 
fairly  easily  corrected  when  hygienic  care  of  the  oral  and  buccal 
cavities  is  established.  Nervous  disorders  in  children  may  have 
their  origin  in  some  of  the  above  named  defects.  The  nurse  can 
not  place  too  much  emphasis  on  the  value  of  their  prompt  cor- 
rection. "  One  result  of  five  years'  work  (in  mouth  hygiene  work 
at  Bridgeport,  Conn.)  is  an  average  reduction  of  33.9  per  cent 
in  the  number  of  cavities  in  the  permanent  teeth  of  the  fifth 
grade  cliildren  .  .  .  No  repair  work  had  been  provided  for 
these  childreii;  the  work  consisted  of  prophylactic  treatments, 
toothbrush  drills,  and  instruction  in  mouth  hygiene."  (See  1919 
Report  of  the  U.  S.  Commissioner  of  Education.) 

8ore  Eyes  amd  Blind^iess 
If  in  her  visits  to  the  home  any  child  under  two  weeks  of  age 
is  found  with  sore  eyes,  the  nurse  is  required  by  Section  288, 
paragraphs  3  and  4  of  the  Penal  Code  to  report  the  fact  immedi- 
ately to  the  local  health  officer  or  to  a  local  qualified  practitioner 
of  medicine.  Failure  to  comply  with  this  law,  or  for  the  nurse 
to  undertake  to  treat  the  case  without  medical  advice  is  a  mis- 
demeanor. The  penalty  for  a  misdemeanor  is  a  fine  of  not  more 
than  two  hundred  dollars  or  imprisonment  of  not  more  than  six 
months  or  both.  Regulation  6,  Chapter  II  of  the  Sanitary  Code 
requires  that  a  visiting  or  public  health  nurse  report  at  once  to 
the  local  health  officer  any  case  of  disease  presumably  com- 
municable.    These  two  laws,  therefore,  make  it  mandatory  that 


198  State  Department  of  Health 

all  cases  of  inflamed  or  sore  eyes  in  infants  shall  be  reported  at 
once  by  the  nurse  to  the  local  health  officer.  Many  nurses  do  not 
know  this  fact.  A  smear  of  the  discharge  may  be  made  and  sent 
to  the  State  Laboratory  at  Albany  to  facilitate  diagnosis. 

If  any  person  is  found  blind  or  in  danger  of  blindness  and  not 
under  medical  care  the  nurse  should  inform  the  New  York  State 
Commission  for  the  Blind.  The  Commission  will  promptly  insti- 
tute measures  for  prevention  or  relief. 

The  Eyes  and  Ears  of  School  Children  * 

"The  State  Medical  Inspection  Law  (Laws  of  1913,  chapter 
627)  provides  that  medical  inspectors  or  principals  and  teachers 
in  charge  of  public  schools  shall  make  eye  and  ear  tests  of  the 
pupils  in  such  schools  at  least  once  in  each  school  year,  and  that 
the  school  authorities  shall  be  furnished  with  '  suitable  mles  of 
instruction  as  to  tests  and  examinations'  so  made,  together  with 
test  cards,  blanks,  record  books  and  other  useful  appliances  for 
carrying  out  the  purposes  of  this  article. 

In  compliance  with  this  law,  the  State  Commissioner  of  Educa- 
tion prescribes  the  following: 

"Instructions  to  Teachers,  for  Examination  of  the  Eyes  and  Ears 
of  School  Children 

1  The  aim  of  the  school  tests.  The  mere  examination  of  eyes 
and  ears  and  recording  of  statistics  are  of  no  value  to  the  children. 
Unless  their  defects  of  vision  and  hearing  and  any  other  eye  and 
ear  troubles  that  are  discoverable  by  the  teacher  are  brought  to 
the  attention  of  parents  and  guardians,  the  examination  will  fail 
of  its  purpose.  But  this  is  not  all.  A  child  is  not  relieved  by 
merely  telling  his  parent  or  guardian  that  he  has  a  remediable 
trouble  of  the  eye  or  ear.  The  case  must  be  taken  to  a  competent 
eye  or  ear  specialist  who  should  report  to  the  school  on  the  blank 
provided  for  this  purpose. 


*  Copy  of  circular  issued  by  the  New  York  State  Department  of  Rlucation. 


Public  Health  ISTuksing  109 

"  This  should  always  be  done  through  the  activity  of  the  family 
physician  who  either  attends  the  case  himself  or  refers  it  to  an 
expert  on  eye  or  ear  conditions, 

"  One  of  the  objects  of  the  medical  inspection  law  is  to  prevent 
every  possible  case  of  preventable  disease  from  developing  among 
school  children  and  to  apply  the  right  remedies  to  every  case  of 
disease  or  defect  that  can  be  cured  or  relieved  while  in  school. 
The  law  gives  the  teacher  a  large  share  of  responsibility  in  attain- 
ing this  object. 

"  2  Time  of  the  tests.  These  tests  should  be  made  as  soon  as 
possible  after  the  beginning  of  the  school  year  in  order  that  the 
defects  thus  discovered  may  receive  early  attention.  Pupils  enter- 
ing school  after  the  regular  tests  have  been  made  should  be  tested 
as  promptly  as  possible.  The  date  of  the  test  should  be  entered 
on  every  pupil's  record. 

"  3  Conditiom  of  tests.  Tests  should  be  made  under  uni- 
form conditions,  as  nearly  as  possible,  and  these  conditions  should 
be  the  most  favorable  that  can  be  attained.  Tests  of  vision  should 
be  made  in  the  forenoon,  if  convenient,  and  never  after  3  p.  m. 
If  the  day  appointed  should  happen  to  be  cloudy  or  dark  it  would 
be  necessary  to  postpone  the  tests,  unless  proper  artificial  light 
were  available. 

"Children  should  always  be  examined  singly  and  should  be 
screened  from  the  sight  of  the  rest  of  the  class.  If  possible,  a 
separate  room  should  be  used  for  these  tests. 

"  4  Persoiml  liMory  of  pupil.  The  following  facts  should  be 
recorded  for  each  pupil,  regardless  of  age: 

a  ]^ame 

h  School  and  grade 

c  Date 

d  Age  (date  of  birth) 

e  What  serious  illnesses  have  you  ever  had  ?  (date  if  possible) 

/  Do  you  have  headaches?  How  often,  how  severe,  and  in 
what  part  of  the  head?  Are  they  afternoon  headaches? 
Worse  after  using  the  eyes  ?  Absent  on  Saturday  or  Sun- 
day ? 

g  Do  you  have  pain  in  the  eyes? 


200  State  Department  of  Health 

Ih    Do  you  have  dizziness  or  nausea?     (Are  you  ^  sick  at  the 

stomach? ') 
i    Do  you  have  trouble  in  reading  the  book  or  blackboard  ? 
j    Do  you  often  '  see  double  ? ' 
h    Do  you  have  earache  ?    How  often  and  how  severe  ? 

I  Did  you  ever  have  running  ears?     (date  if  possible) 
m  Do  you  breathe  through  your  nose  easily  ? 

II  Do  you  think  you  can  hear  as  well  as  other  children  ? 

0  Do  you  have  frequent  colds  in  the  head,  with  discharge  from 
the  nose  and  throat  ? 

"  Young  children  do  not  give  reliable  answers  to  the  above  ques- 
tions. The  teacher  should,  if  possible,  secure  the  desired  informa- 
tion from  parents  or  older  brothers  and  sisters.  When  a  child's 
history  is  unfavorable  in  respect  to  the  points  just  mentioned,  his 
parents  should  secure  competent  medical  advice  for  him,  without 
regard  to  the  results  of  the  eye  and  ear  tests  described  below. 
The  physician  to  whom  the  case  is  referred  should  report  to  the 
school  on  the  blank  provided  for  this  purpose. 

"  5  Observation  by  teacher  or  nurse.  The  teacher  will  often  be 
able  to  answer  some  of  the  questions  on  the  above  list.  She 
should  also  record  the  results  of  her  observations  of  each  pupil 
under  the  following  heads,  not  depending  on  the  child's'  state- 
ments alone: 

a  Are  the  child's  eyes  straight  ?  Is  he  cross-eyed  or  '  wall- 
eyed ? ' 

h  Does  he  squint  or  frown  habitually  ? 

c  Can  he  read  from  the  blackboard  as  readily  as  other  pupils  ? 

d  Does  he  hold  his  book  12  to  14  inches  from  the  eyes? 

e  Does  his  pos-ture  while  reading  indicate  any  difficulty  in  see- 
ing distinctly? 

/  Is  he  easily  fatigued,  and  does  the  use  of  his  eyes  appear  to 
increase  fatigue  ? 

g  Are  the  eyes  healthy  in  color  and  appearance? 

h  Are  the  eyelids  healthy  in  color  and  appearance? 

i  Does  it  seem  that  the  child's  eyes  are  oversensitive  to  light? 

j  Does  he  seem  to  hear  easily   at  ordinary  distances  ? 


Public  Health  Nursing  201 

h  Does  his  posture  or  attitude  indicate  any  difficulty  in  hear- 
ing? 

I  Does  he  often  say  "  What  ?"  when  asked  a  question,  or  ask 
you  to  repeat  the  question  ? 

m  Is  he  usually  attentive  and  interested  in  what  others  are  say- 
ing? 

n  Do  the  ears  look  healthy  ? 

0  Are  the  ears  obstructed  by  wax  ? 

"  The  above  items  constitute  a  personal  history  of  the  child  and 
are  of  great  significance  in  deciding  whether  the  child  shall  be 
sent  to  a  doctor  for  further  examination  and  diagnosis.  Doubt- 
ful or  unfavorable  answers  to  any  of  these  questions  would  war- 
rant the  teacher  in  warning  the  parents  concerning  the  child's 
eyes  or  ears, 

"  Defects  of  vision  and  hearing  are  often  insidious  in  their  ori- 
gin and  development.  For  this  reason,  children  in  school  should  he 
observed  closely  in  order  to  detect  the  first  indications  of  failing 
sight  or  hearing.  When  defects  are  found  or  even  suspected,  the 
child  should  have  the  advantage  of  expert  examination  and  treat- 
ment without  any  hesitation  or  unnecessary  delay.  Above  all 
things',  the  school  authorities,  m.cdical  inspector  and  nurse  should 
make  the  required  examinations  and  tests  with  a  full  knowledge  of 
their  significance. 

"  6  Preparation  for  tests  of  vision;  apparatus,  etc.  The  teacher 
should  secure  the  information  called  for  above  before  beginning 
the  tests  of  vision  and  hearing.  She  should  then  study  the  fol- 
lowing directions  most  carefully  and  see  that  all  preparations  have 
been  completed. 

"  The  tests  of  vision  are  made  by  using  a  Shiellen's  Test  Card 
containing  letters  and  '  inverted  E's '  adapted  to  the  vision  of  the 
normal  eye  at  distances  of  200,  100,  70,  50,  40,  30  and  20  feet 
respectively.  The  Snellen  card  can  be  obtained  from  local  op- 
ticians, printers  of  school  blanks,  etc.  The  card  should  be  kept 
well  protected  from  light  and  dust  and  should  never  he  exhibited 
to  the  pupils  except  during  the  test  of  vision  as  children  readily 
memorize  the  letters. 

The  card  should  be  hung  with  the  20-foot  line  on  a  level  with 


202  State  Department  of  Health 

the  child's  eyes.  It  should  be  well  illuminated  and  should  not  re- 
flect a  strong  light  into  the  eyes  of  the  child.  It  should  be  out  of 
sight  of  the  class.  The  child  should  sit  directly  in  front  of  the 
card  at  a  distance  of  exactly  20  feet  between  the  eyes  and  the  card. 
There  should  be  no  cross  lights  or  reflections  from  windows  or 
blackboards  to  dazzle  the  child  during  the  test. 

While  conducting  the  test  the  teacher  should  stand  near  the 
test  card.  If  it  seems  desirable  she  may  point  to  the  letters,  using 
an  ordinary  '  pointer.'  She  must  not  interfere  with  the  illumi- 
nation of  the  card,  nor  obstruct  the  children's  view. 

"7  Tests  of  vision — to  he  applied  to  children  7  years  of  age 
or  older,  a  Children  having  glasses  should  be  tested  with  their 
glasses  properly  adjusted  to  their  faces.  If  necessary  they  should 
be  sent  to  an  expert  for  a  fitting  before  the  test  is  made.  They 
should  then  be  tested  without  their  glasses  and  the  results  of  the 
two  tests  should  be  carefully  compared  to  ascertain  the  degree  of 
relief  afforded  by  the  glasses. 

"  b  Children  who  are  under  the  care  of  physicians  must  have 
these  tests  made  and  recorded  the  same  as  those  who  have  no 
regular  medical  care. 

"  c  Seat  the  children  20  feet  in  front  of  the  Snellen  chart.  See 
that  the  chart  is  well  illuminated,  as  described  in  section  6,  and 
that  the  child's  eyes  are  on  a  level  with  the  20-foot  line. 

"  Instruct  the  child  to  cover  the  left  eye  w4th  clean  screen 
(heavy  cardboard  is  good)  held  against  the  nose.  Do  not  allow 
the  child  to  cover  the  eye  with  the  hand  or  make  any  pressure 
whatever  on  the  eyeball,  as  it  will  interfere  with  the  test  of  the  left 
eye  later  on. 

"Ask  the  child  to  read  the  letters  aloud,  in  regular  order,  begin- 
ning with  the  top  line.  Make  a  note  of  the  smallest  line  that  he 
reads  with  no  more  than  three  errors  in  naming  the  letters. 

"  In  the  same  manner  ask  the  child  to  cover  the  right  eye  and 
name  the  letters  from  the  top  line  to  the  bottom,  in  the  reverse 
order  —  from  right  to  left.  This  is  done  to  prevent  the  child  yc~ 
peating  the  letters  from  memory,  ISTotes  the  smallest  line  tliat  lie 
reads  with  the  left  eye,  with  three  errors  or  less. 

"  d  Use  of  '  inverted  E's.'  For  the  child  who  does  not  know 
all  the  letters,  '  inverted  E's  '  are  included  in  eveiy  line  of  the 


Public  Health  Nursing  203 

card.  The  child  should  be  instructed  to  indicate  by  his  extended 
fingers  the  position  of  the  E  as  pointed  out  by  the  examiner.  In 
other  words,  the  child  holds  his  open  hand  with  the  fingers  point- 
ing up,  down,  right  or  left,  as  in  the  character  pointed  out. 

"  It  is  well  to  have  a  large  letter  E  cut  from  cardboard  or  sheet 
metal  which  the  child  can  hold  to  represent  the  position  of  the 
letter  pointed  out  by  the  teacher.  Note  the  lowest  line  in  which 
he  sees  the  E's  with  not  more  than  three  errors. 

"  e  Memorizing.  If  it  is  suspected  that  the  answers  are  being 
made  from  memory  a  hole  about  one  and  one-half  inches  square 
may  be  cut  in  a  strip  of  cardboard  so  as  to  allow  only  one  or  two 
letters  to  show  through  the  hole,  rnd  by  skipping  around  rapidly 
it  is  easy  to  break  up  the  memorizing  of  the  letters.  This  method 
may  be  of  use  also  in  testing  little  children.      (See  7  /.) 

'"''  /  Eecord  of  distant  vision.  The  letters  of  Snellen's  Test  Type 
are  standardized  for  certain  distances  from  the  normal  eyes. 
Thus,  the  letters  marked  100  are  readily  distinguishable  by  the 
noi-mal  eye  at  a  distance  of  100  feet;  those  marked  40,  30,  20, 
etc.,  are  each  distinguished  normally  at  the  corresponding  number 
of  feet  from  the  observer. 

"  The  child's  visual  power  is  rated  by  a  fraction,  of  which  the 
numerator  is  his  distance  from  the  test  letters  —  in  this  case  20 
feet.  The  denominator  of  the  fraction  is  the  number  belonging  to 
the  smallest  line  of  letters  that  he  reads  without  more  than  three 
errors.  If  he  reads  the  20-foot  line  passably  with  the  right  eye 
his  vision  is  recorded  as  R  20/20.  If  he  fails  on  the  20-foot  and 
30-foot  lines  and  reads  the  40-foot  line  his  vision  is  R  20/40. 

"  When  the  child  fails  on  all  the  lines  he  should  go  nearer  the 
chart,  say  10  feet,  and  try  the  test  as  before.  The  numerator  of 
his  fraction  will  then  be  10,  and  he  may  be  rated  as  R  10/100  or 
R  10/70,  etc.  When  the  child  takes  a  position  nearer  than  20 
feet,  he  should  be  tested  on  several  lines,  and  not  on  the  same  line 
only,  with  each  change  of  position. 

"  Be  sure  to  measure  carefully  the  child's  distance  from  the 
chart.  "  Pacing  "  the  distance  or  estimating  it  in  any  other  way 
is  absolutely  inexcusable,  because  liable  to  be  very  inaccurate. 

"  Remember  that  if  the  vision  of  one  eye  is  poorer  than  that  of 
the  other  eye,  it  may  be  due  to  pressure  on  the  eye  from  the  hand 


204-  State  Department  of  Health 

that  covers  it.     Do  not  allow  either  eye  to  be  pressed  upon  while 
the  other  is  being  tested  ! 

''  When  a  child  reads  the  letters  correctly,  but  very  slowly,  or 
with  much  hesitation  the  fact  should  be  noted  by  the  teacher,  and 
an  explanation  should  be  found  if  possible.  The  teacher  should 
also  observe  and  record  the  child's  posture  and  general  attitude. 
The  position  of  the  head,  and  the  expression  of  the  face  may  be 
positive  evidence  of  eyestrain. 

"  Little  children  often  transpose  the  letters  in  reading  This  is 
a  pecularity  of  child  psychology  and  has  notliing  to  do  with  the 
rating  of  the  vision.  The  use  of  the  cardboard  aperture,  described 
in  7  e,  will  prevent  transposition. 

"  8  Notification  of  parents  and  guardians.  When  the  visual 
power  is  20/30  or  less,  for  one  eye  or  both,  the  child  should  be  re- 
ferred to  a  specialist  for  further  diagnosis  and  advice.  The  same 
course  should  be  followed  if  the  child's  condition  suggests  eye- 
strain or  eye  disease. 

"  If  a  child  wearing  glasses  fails  to  do  well  with  the  tests  of 
vision,  or  if  his  glasses  do  not  seem  fully  to  relieve  his  disability 
he  should  be  referred  to  a  specialist,  who  should  certify  that  the 
child  has  received  the  necessary  attention. 

"  Testing  of  hearing  —  for  children  of  all  ages. 

"  a  Directions  for  testing.  The  room  in  which  these  tests  are 
given  should  be  not  less  than  25  or  30  feet  long  and  as  quiet  as 
any  that  can  be  found.  The  windows  and  doors  should  be  closed. 
The  floor  should  be  ruled  with  parallel  lines  one  foot  apart  and 
the  child  should  sit  in  a  revolving  chair  on  the  first  line.  No 
other  pupils  should  be  in  the  room  during  the  test.  The  examiner 
should  be  a  person  of  normal  hearing,  as  determined  by  the  test, 
and  should  stand  at  a  measured  distance  of  20  feet  from  the  child. 
There  should  be  nothing  back  of  the  examiner  that  could  act  as  a 
sounding  board  —  such  as  a  door  or  a  vibrating  wall. 

"  I^ofore  making  these  tests  the  examiner  should  ascertain,  by 
practice  with  persons  of  normal  hearing,  how  to  regulate  the 
whispered  or  low-spoken  voice  so  that  it  will  be  heard  plainly  at  a 
distance  of  not  more  than  25  feet, 

"The  child  shcmhl  ])C  instructed  to  tuni  the  right  ear  towards 
the  examiner,  and  to  i>hu'e  the  finder  in  the  left  ear  firmly  enouffli 


Public  Health  Nursing-  205 

to  prevent  hearing.  He  should  be  told  to  listen  attentively,  with 
his  eyes  closed  and  to  repeat  the  numbers  that  the  examiner 
whispers  to  him. 

"  The  examiner  then  pronounces  a  number  of  two  or  more  sylla- 
bles, such  as  "  fifty-four,"  in  a  whispered  or  low-spoken  voice  of 
moderate  intensity.  The  child  will  repeat  correctly  three  out  of 
five  such  numbers  if  his  hearing  is  normal.  If  not,  the  examiner 
moves  a  foot  or  two  nearer  and  pronounces  another  series  of  five 
numbers,  keeping  up  this  procedure  until  the  child  hears  dis- 
tinctly three  or  more  of  tlie  five  numbers.  The  examiner  notes 
the  distance  at  which  the  right  ear  hears  distinctly,  and  then  tests 
the  left  ear  in  the  same  manner. 

"  It  is  important  not  to  correct  the  child's  responses  to  the  test 
but  to  proceed  as  though  all  the  lesults  were  favorable.  The  ex- 
aminer should  also  aim  to  maintain  the  same  quality  and  volume 
of  voice  throughout  the  tests  and  to  pronounce  the  syllables  with 
equal  emphasis,  speaking  deliberately  and  distinctly.  For  this 
reason  it  is  best  that  the  same  examiner  should  test  the  entire 
school  in  order  that  the  results  may  be  impartial. 

"  h  Record  of  hearing  tests.  The  record  is  made  in  the  form  of 
a  fraction,  having  for  its  denominator  the  distance  at  which  the 
whisper  is  audible  by  the  normal  ear,  that  is  20  feet,  and  for  the 
numerator  the  actual  distance  at  which  the  child  hears  well.  If 
the  child's  right  ear  hears  nonnally,  or  at  20'  feet,  his  record  is 
R  20/20.  If  with  his  left  ear  he  hears  the  test  words  at  a  dis- 
tance of  only  8  feet  his  record  is  L  8/20. 

''  c  Alternative  riiethods.  A  child  who  is  too  young,  careless  or 
inattentive  to  respond  fairly  to  the  whispered  numbers  may  be 
placed  with  his  back  to  the  examiner  at  a  distance  of  20  feet  and 
told  to  close  one  ear  as  in  the  preceding  directions.  The  examiner 
then  whispers  an  order  such  as :  '  Hold  up  your  right  hand,'  or 
'  Open  the  door.'  The  greatest  distance  at  which  the  whispered 
order  is  carried  out  is  used  as  numerator  of  the  hearing  record 
for  the  ear  undergoing  the  test. 

''  d  Form  of  permmient  record.  The  school  blank  form  is 
designed  to  record  the  results  of  the  hearing  tests. 

''  Notification  and  foUow^ip  luorh.  Any  impairment  of  the 
hearing,  however  slight,  is  a  serious  menace  to  the  future  well- 


206  State  Department  of  Health 

being  of  the  child.  Deafness  is  often  of  slow  and  gradual  de- 
velopment and  the  merest  suspicion  of  its  onset  ought  to  be  the 
signal  for  expert  medical  examination  and  treatment.  For  these 
reasons  the  teacher  is'  urged  to  notify  the  parent  or  guardian  when 
the  child  does  not  give  a  satisfactory  response  to  the  tests  for 
hearing.  Any  unsatisfactory  answers  to  the  questions  in  sections 
4  and  5  should  also  be  regarded  as  sufficient  ground  for  asking 
parents  or  guardians  to  seek  medical  counsel  for  the  child  in  order 
to  prevent  more  serious  ear  trouble  in  the  future, 

"Importance  of  proinpt  relief  of  defects  of  eyes  and  ears. 
The  child's  eye,  like  the  rest  of  his  body,  lacks  the  strength  and 
endurance  of  the  adult's.  The  child's  eye  is  readily  deformed 
and  drawn  out  of  shape  by  a  stress  or  strain  that  would  easily  l>e 
endured  by  the  adult's.  Every  physician  learns  from  observation 
that  the  eye  troubles  of  a  child  are  likely  to  grow  worse  unless  the 
eyes  are  properly  relieved  by  making  their  work  easier  or  by  the 
use  of  glasses. 

"  '  Squint  eye,'  '  cross-eyes,'  or  strabismus,  if  beginning  early 
may  progress  until,  at  the  age  of  10  years,  unequal  traction  on  the 
delicate  eye  muscles  has  changed  a  pretty  face  into  a  pathetic  cari- 
cature and  greatly  reduced  the  visual  power. 

"  '  Near-sighted  '  or  myopic  eyes  tend  to  become  worse  instead 
of  better,  and  by  constant  distortion  of  the  eyeballs  may  end  in 
partial  blindness. 

"  It  is  a  costly  mistake  to  assume  that  the  school  child  will  '  out- 
grow' any  defect  of  vision.  The  truth  is  that  defects  usually 
grow  more  numerous  and  more  serious  as  the  child  grows  older. 
Eyestrain  is  likely  to  develop  near-sightedness  and  this  leads  to 
impairment  of  vision.  '  Cross-eyed  '  children  grow  into  '  cross- 
eyed' men  and  women  and  often  suffer  from  the  weakening  of 
one  or  both  eyes.  Inflammatory  disease?  of  the  eyes,  as  a  rule, 
tend  to  become  chronic  or  more  disabling  unless  promptly  treated. 

"  Every  school  child  with  signs  of  any  of  these  defects,  and 
every  child  annoyed  by  dizziness,  nervousness,  headaches,  '  seeing 
double,'  styes  or  other  troubles  traceable  to  eyestrain  should  have 
the  services  of  an  expert  in  diagnosis  and  treatment  of  eye  dis- 
orders; and  under  no  conditions  should  the  examination  and  treat- 
ment of  the  eyes  be  postponed  until  '  a  more  convenient  season.' 


Public  Health  E'ursing  207 

"  It  is  equally  important  to  attend  promptly  to  every  child 
whose  hearing  is  impared.  Defects  of  hearing  are  liable  to  grow 
more  serious  with  age.  The  child  hears  less  and  less  of  what  is 
going  on  around  him  and  profits  less  from  the  school  and  from 
human  intercourse  in  general.  There  is  no  other  physical  defect 
that  retards  the  child's  progress  in  school  so  hopelessly  as 
defective  hearing,  without  adequate  relief. 

"  Every  case  of  suspected  adenoids  or  enlarged  tonsils  and 
every  case  of  mouth  breathing  should  have  prompt  examination 
and  treatment  by  a  competent  physician.  Neglect  of  these  con- 
ditions may  lead  to  the  development  of  serious  complications  in 
the  ear,  the  mastoid  cells  and  other  adjacent  structures. 
Frequently  recurring  nasal  catarrh  also  should  have  thorough 
treatment  because  it  is  liable  to  extend  from  the  no,se  through  the 
connecting  channels  to  the  middle  ear,  where  it  may  cause  abscess 
or  chronic  inflammatory  disease,   and  deafness. 

"  Excessive  accumulations  of  wax  in  the  ear  may  cause  distress 
or  deafness.  Although  it  may  seem  easy  to  remove  wax  from  the 
ear,  this"  should  not  be  attempted  by  an  inexperienced  person  as 
serious  damage  might  be  done  to  the  ear  drum." 

Education  of  the  Blind  Child 
All  blind  persons  of  suitable  age  and  capacity  for  instruction 
who  are  legal  residents  of  the  State  of  New  York  are  entitled  to 
education  without  charge  in  the  State  School  For  the  Blind.  The 
application  for  admission  should  be  made  to  the  board  of  trustees 
of  the  State  School.  Paragraph  993  of  the  Education  Law  directs 
that  the  application  be  accompanied  by  a  certificate  from  the 
county  judge  or  county  clerk  or  the  supervisor  or  clerk  of  the 
town  or  the  mayor  of  the  city  where  the  child  resides  "  setting 
forth  that  the  applicant  is  a  legal  resident  of  the  town,  county 
and  state  claimed  as  his  residence." 

The  Deaf  Child 
If   a  deaf  mute  under  the   age   of   12   years  becomes  or  is 
in  danger  of  becoming  a  public  charge  the  public  health  nurse 
should  apply  to  the  local  overseer  of  the  poor  or  commissioner 


208  State  Department  of  Health 

of  charity  or  to  the  to^^^l  supervisor,  or  if  in  a  city  to  the  ward 
supervisor  to  have  the  child  placed  in  a  state  institution  for 
education.  The  law  is  mandatory  that  all  such  children  shall 
upon  application  be  provided  for.  Their  maintenance  is  a  charge 
upon  the  county.  The  State  Board  of  Charities  should  also  be 
informed  of  the  case. 

Orthopedic  Defects 

These  defects  are  probably  much  more  prevalent  than  is  gen- 
erally believed.  Miss  Jessie  Bancroft,  Assistant  Director  of  'Phy- 
sical Training  in  the  public  schools  of  New  York  City  estimates 
that  "  probably  80  per  cent  of  so-called  normal  children  have 
antero-posterior  faults  of  posture."  She  also  estimates  "  that  85 
per  cent  of  the  time  spent  in  school  calls  necessarily  for  positions, 
the  influence  of  which  is  toward  poor  posture,  that  the  balance  of 
15  per  cent  is  vitiated  in  its  possible  influence  by  poor  furniture, 
poor  light,  fatigue,  physical  defects,  etc.,  and  that  only  11  per  cent 
of  the  time  (physical  training  and  singing)  makes  actively  for 
good  posture."  * 

Dr.  Lloyd  T.  Brown  in  the  examination  of  700  school  children 
in  the  Boston  public  schools  found  three-fourths  of  the  children 
in  bad  posture,  one-third  of  the  boys  and  three-fifths  of  the  girls 
had  faulty  weight  bearing  foot  posture.  The  tendency  to  bad 
posture  increased  as  the  children  advanced  to  higher  grades, 
while  in  the  high  school  "  bad  posture  was  nearly  twice  as  common 


the  body  has  a  definite  relation  to  faulty  use  of  the  feet.  This 
should  be  a  very  important  point  in  the  care  and  hygiene  of  our 
school  children."  f 

J  Dr.  Hills  Cole  at  the  Fourth  International  Congress  on 
School  Hygiene  said:  "We  must  conclude  that  foot  strain  in 
school  children  is  more  common  than  eye  strain,  and  its  effects  are 
just  as  serious.     It  is  caused  by  the  muscular  effort  involved  in 


•  Report  of  Traiisactior.e  of  Fourth  International  Congress  on  School 
Hvffiene,  Vol.  IV 

t  Report  of  Transactions  of  Fourth  International  Congress  on  School 
Hygiene,  Vol.  V. 

t  Weak  Ankles,  Flat  Foot,  Spinal  Curvature  in  School  Children,  by  Hills 
Cole,  M.  D.,  Monthly  Bulletin  of  State  Department  of  Health,  October,  1913. 


Public  Health  Nursing  209 

balancing  the  weight  of  the  body  in  a  shoe,  the  bottom  of  which 
is  smaller  than  the  bottom  of  the  foot.  If  the  foundation  of  a 
school  building  did  not  come  out  as  far  as  the  side  walls  the  pupils 
would  be  constantly  menaced  by  the  liability  of  the  structure  to 
collapse.  A  weak  ankle  or  flat  foot  is  a  foot  that  has  rolled  inward 
over  the  shoe  bottom  because  the  strain  on  the  muscles  whose 
function  it  is  to  hold  up  the  inner  arched  border  of  the  foot  has 
caused  them  to  lose  their  grip  and  to  let  the  weight  of  the  body 
rotate  the  foot  inward  and  downward. 

"  Foot  strain  is  also  a  matter  of  vital  moment  to  the  school 
teacher. 

"  If  the  foot  rolls  inward  under  the  body  weight  unnatural 
pressure  is  brought  on  the  side  of  the  great  toe  joint,  and  a 
'  bunion  '  is  produced. 

"  If  the  toes  are  cramped  in  shoes,  the  muscles  of  the  foot  can 
not  act  freely  and  strain  is  put  upon  the  other  muscles  in  the 
effort  of  walking. 

"  If  the  shoes  are  made  on  a  twisted  last,  walking  is  more  of 
an  effort  than  it  should  be.  High-heeled  shoes  throw  undue  weight 
on  the  ball  of  the  foot,  and  at  the  same  time  make  the  foundation 
upon  which  the  weight  of  the  body  has  to  be  borne  less  secure; 
each  defect  involves  muscle  strain  in  the  endeavor  to  minimize 
its  effects. 

"  Eolling  of  the  foot  interferes  with  the  circulation  in  the  foot 
and  leads  to  swelling,  which  fills  up  the  hollow  of  the  arch  and 
adds  to  the  appearance  of  flatness. 

"  In  addition  to  these  primary  effects,  we  have  secondarily  a 
natural  diminution  of  the  general  efficiency  of  the  sufferer  from 
foot  strain.  If  the  feet  are  demanding  more  than  their  share 
of  the  body's  output  of  nerve  force  or  vital  energy,  some  other 
part,  or  the  body  as  a  whole,  must  get  less  than  its  share.  If 
there  is  any  foot  suffering  for  the  mind  to  dwell  upon,  the  pupil  or 
teacher,  as  the  case  may  be,  must  give  less  attention  to  the. lessons ; 
and  the  demands  of  the  modern  school  curriculum  are  surely 
exacting  enough  to  call  for  all  the  vital  energy  pupil  or  teacher 


"  For  the  prevention  of  or  relief  from  weak  ankles  or  flat  foot, 
a  shoe  must  be  worn  in  which  the  body  weight  is  properly  dia- 


210  State  Department  of  Health 

tributed,  and  with  a  bottom  so  planned  that  the  foot  has  no 
tendency  to  roll  o\'er  it.  It  is  not  sufficient  to  give  plenty  of 
room  for  the  toes;  it  should  be  a  straight  shoe  to  conform  to  the 
natural  axis  of  the  foot ;  a  firm  sole  gives  stability  to  the  founda- 
tion without  necessarily  interfering  with  muscle  action;  but  above 
all,  the  rear  half  of  the  shoe  must  be  right  as  this  is  the  most 
important  part  since  it  receives  the  body  weight ;  the  shani 
between  the  sole  and  heel  should  be  short  and  wide  and  so  placed 
on  the  shoe  as  to  meet  all  the  lines  of  weight  thrust,  forward  and 
lateral  extension  of  the  heel  being  employed  for  this  purpose. 

"  Too  much  care  can  not  be  given  to  the  correct  shoeing  of  chil- 
dren, not  only  for  the  sake  of  conserving  the  health  and  happiness 
of  the  child,  but  also  with  an  eye  to  the  future  that  there  may  be  no 
crippling  of  the  feet  in  any  degree  to  act  as  a  bar  to  progress  dur- 
ing the  later  productive  years  of  life. 

"As  to  the  spinal  curvatures  dependent  upon  foot  weakness,  if 
pronation,  of  the  foot  is  prevented  by  a  shoe  constructed  along  the 
lines  indicated,  the  curvature  will  gradually  correct  itself.  \Vlien 
the  foundation  is  scientifically  constructed,  the  superstructure  is 
plumb." 

Many  parents  belie^^e  their  children  will  with  increasing  years 
outgrow  these  childhood  defects,  and  therefore  neglect  to  care 
for  them.  Instead  of  outgrowing  them  only  too  frequently  the 
result  is  a  general  systemic  disturbance  which  still  further 
incapacitates  the  child  in  the  general  competition  for  a  place 
among  his  fellows. 

Since  faulty  posture  and  spinal  defonnity  are  frequently  caused 
by  general  muscular  weakness  due  to  faulty  nutrition  or  unhy- 
gienic home  conditions,  the  nurse  will  need  not  only  to  strive  to 
prevent  the  development  of  these  defects  but  to  participate  in  the 
work  of  securing  their  correction.  To  accomplish  this  the  dietary 
of  the  child  will  require  her  attention. 

Malnutrition 

To  correct   faulty  nutrition   of  the  child   frequently  involves 

changing  the  food  habits  of  the  entire  family.     Many   of  the 

children  may  be  taught  good  habits  through  nutrition  classes  in 

the  school ;  for  others  intensive  home  work  will  be  needed  before 


Public  Health  Nursing  211 

progress  will  be  made.  Sometimes  the  mother  will  need  to  be 
induced  to  change  the  disposition  of  the  entire  family  income 
before  the  diet  will  be  adapted  to  the  needs  of  the  different  mem- 
bers of  the  household.  This  may  sometimes  be  accomplished 
through  neighborhood  classes;  sometimes  it  calls  for  individual 
instruction  in  the  home,  and  a  good  knowledge  of  budget  making. 
It  will  be  necessary  to  consider  what  the  local  market  offers,  and 
what  the  family  income  is.  A  good  deal  of  enthusiastic  com- 
petition may  be  developed  among  the  mothers  or  possibly  the 
older  girls  of  the  family  in  preparing  desirable  dishes  or  bringing 
the  children  up  to  the  standard.  It  is  important  that  the  nurse 
should  understand  that  nutrition  is  intimately  involved  with  other 
matters  of  personal  health,  such  as  good  teeth,  vision,  hearing, 
posture,  and  even  with  mentality,  and  that  with  nutritional  im- 
])rovement  she  may  look  to  find  other  defects  tending  toward  cor- 
rection. Much  good  literature  is  available  for  guidance  in  this 
field,  and  the  New  York  State  Department  of  Education  has 
special  instnictors  who  are  supervising  the  development  oi 
methods  in  all  public  schools  of  the  State.  Parent-Teacher  Asso- 
ciations will  frequently  take  over  the  ways  and  means  of  securing 
funds  for  demonstration.  The  Junior  Ked  Cross  is  an  invaluable 
ally  in  helping  to  "  get  things  across,"  particularly  the  things 
which  make  for  healthier  boyhood  and  girlhood. 

Any  child  10  per  cent  or  more  underweight  should  be  placed 
in  the  nutrition  class. 

After-Care  of  Infantile  Paralysis 

In  addition  to  the  minor  orthopedic  defects  cited  in  the  pre- 
ceding section,  there  are  found  in  nearly  every  community  of  the 
state  children  and  adults  who  are  seriously  lame  or  deformed, 
and  who  are  going  about  with  a  twisted  contorted  gait  or  with  the 
aid  of  crutches,  or  who  may  even  be  confined  to  a  wheel  chair. 

The  majority  of  these  cases  have  resulted  from  the  effects  of 
poliomyelitis  (infantile  paralysis)  where  there  has  been  no  treat- 
ment or  the  treatment  was  inefficient  or  not  continued  sufficiently 
long.  A  few  of  the  cases  are  beyond  all  help,  but  the  majority 
can  be  greatly  benefited  by  hospital  care,  operations  and  proper 
apparatus  and  can  thus  be  restored  to  school  life  or  enabled  to 


212  State  Department  of  Health 

earn  a  partial  or  comjjlete  livelihood.  The  State  Department  of 
Health  employs  an  orthopedic  surgeon  and  a  staff  of  specially 
trained  nurses,  each  in  cha;rge  of  a  district,  who  are  at  the  ser- 
vice of  any  community  free  of  charge.  Should  a  nurse  discover 
any  cases  of  infantile  paralysis  or  after  effects  of  that  disease, 
which  are  not  receiving  medical  or  surgical  attention,  she  should 
report  to  the  local  health  officer  or  school  inspector,  or  directly  to 
the  State  Department  of  Health,  and  the  services  of  the  orthopedic 
surgeon  and  the  state  nurse  will  be  promptly  given.  K"urses  not 
specially  trained  in  the  management  of  such  cases  should  not 
undertake  their  supervision  until  they  have  received  instructions  in 
each  case  from  experts. 

"  Suggested  Duties  of  the  School  Xuese  * 
"  1  To  assist  the  medical  inspector  or  teacher  in  examining 
children  and  in  keeping  records. 

2  To  visit  the  homes  of  those  needing  treatment  and  to  urge 
its  necessity  on  the  parents. 

3  To  watch  for  any  evidence  of  contagious  diseases  or  con- 
ditions in  the  school,  and  when  found  to  notify  superintendent, 
principal,  teacher,  or  medical  inspector. 

4  To  detect  and  refer  to  the  family  physician,  medical 
inspector  or  dentist  any  evidence  of  eye,  ear,  nose,  or  throat 
trouble  or  other  physical  or  mental  defects. 

5  To  render  first  aid  in  emergency  cases  occurring  in  schools 
and  to  see  that  child  is  taken  either  to  its  home  or  to  the  family 
physician. 

6  To  report  to  the  superintendent  of  schools  or  principal  any 
error  she  may  detect  as  to  light,  heat,  and  ventilation  in  the 
schools',  or  any  improper  seating  or  other  insanitary  conditions. 

7  To  follow  up  absentees  occasioned  by  medical  inspection,  or 
where  contagious  diseases  or  conditions  may  be  suspected. 

8  To  follow  up  recommendations  of  family  physicians,  dentist. 
or  medical  inspector,  and  to  inform  the  superintendent  of  schools 
or  principal  of  results  obtained. 

9  To  accompany  children  in  special  cases  with  written  per- 
mission of  parent  or  guardian,  to  hospital,   dispensary,  family 

*  Prepared  by  the  State  Medical  Inspector  of  Schools. 


Public  Health  Nursing  213 

physician,  oculist,  or  dentist,  and  to  secure  from  such  a  report 
as  to  services  rendered  to  pupils. 

10  To  investigate  and  improve  home  conditions  where  neces- 
sary by  instructing  children  and  parents  in  matters  of  personal 
and  home  hygiene  and  to  bring  home  and  school  closer  together. 

11  To  investigate  reasons  for  truancy  and  to  do  whatever  may 
be  possible  to  remove  home  causes. 

12  To  keep  employers  and  parents  informed  regarding  child 
labor,  compulsoiy  attendance,  medical  inspection,  vaccination  and 
other  laws  bearing  upon  the  health  of  the  school  child. 

13  To  cooperate  with  physicians,  dentists,  school  authorities 
and  others  in  better  conserving  the  health  of  the  child  and  improv- 
ing its  environment,  both  at  home  and  at  school. 

14  To  perform  such  other  duties  as  may  from  time  to  time  be 
prescribed  by  the  board  of  education  or  by  the  medical  inspector." 

Physical  Educatio'jst 

The  jSTew  York  State  law  making  physical  education  compul- 
sory for  all  pupils,  male  and  female,  eight  years  of  age  and  over 
in  public,  private  and  parochial  schools  was  enacted  in  1916.  An 
average  of  at  least  twenty  minutes  a  day  throughout  the  school 
year  is  required  for  the  subject.  The  result  of  this  has  been  the 
development  of  a  syllabus  in  physical  education  which  has  for 
its  objective  the  offering  of  such  stimulation  to  the  potential 
capacity  in  the  child  for  muscular  activity  as  will  "  contribute 
to  the  development  of  bodily  vigor  and  endurance,  muscular 
strength  and  skill,  bodily  and  mental  poise,  and  the  social  and 
moral  qualities  of  courage,  self-control,  self-subordination, 
cooperation  under  leadership  and  disciplined  initiative."  Drills, 
games,  sports,  athletics,  romps  and  gambols  have  become  a  coordi- 
nate part  of  school  activities,  among  which  exercises  specially 
designed  to  correct  existing  physical  defects  have  been  introduced 
as  their  need  has  been  indicated. 

This  introduction  of  a  physical  education  program  as  a  com- 
ponent part  of  general  education  is  having  a  far  reaching 
effect  upon  training  for  citizenship.  ITowhere  is  this  more 
apparent  than  among  industrial  and  commercial  forces.  A  posi- 
tive appeal  has  been  made  to  be  permitted  to  be  bom  fit  and 


214  State  Department  of  Health 

to  remain  fit,  to  know  the  joys  of  life  of  the  free-born  and  to 
spread  the  contagion  of  happiness  that  grows  through  successful 
endeavor.  The  response  to  that  appeal  has  been  to  motivate  health 
conservation.  Rural  people,  always  at  first  somewhat  conservative 
to  new  doctrines,  are  gradually  responding  to  the  appeal.  The 
big  factor  in  so  presenting  the  subject  that  it  will  secure  immediate 
and  hearthy  response  is  the  application  of  the  principles  of 
psycholog}^  to  the  teaching  of  health  conservation. 

The  vital  j)rinciple  governing  the  method  is  to  make  the  subject 
look  so  attractive  that  children  will  be  so  eager  to  possess  it  that 
they  will  nin  after  it  and  be  willing  to  even  make  personal 
sacrifice  to  have  it  for  their  own  enjoyment.  It  is  practically 
identical  with  business  methods  in  salesmanship  involving  good 
advertising.  By  this  method  passive  receptivity  is  transformed 
into  personal  initiative,  enthusiasm  is  aroused,  teams  are  organ- 
ized for  contest  and  competitioji;  in  short,  health  conseiwation 
becomes  good  sport.  It  was  the  physical  inaction  of  former 
methods  of  teaching  hygiene  which  made  it  so  irksome;  learning 
from  books  is  dull  business  for  children  until  they  want  some 
definite  information  and  are  directed  to  a  book  where  they  can 
find  the  thing  they  are  looking  for  to  ap})ly  to  some  situation  in 
which  they  are  interested. 

This  sort  of  presentation  of  the  subject  requires  good  teachers; 
the  demand  for  this  type  of  teacher  has  exceeded  the  supply  and 
is  increasing.  To  get  the  cormnunity's  children  critically  to  look 
over  themselves,  their  homes,  and  their  neighborhoods  and  to 
score  themselves  and  each  other  according  to  a  scale  upon  the  merits 
of  which  they  have  previously  passed  judgment,  to  have  them 
score  their  wells,  privies,  bams,  and  other  in(lis[)ensable  ivquire- 
ments  and  compare  results  with  each  other,  to  have  them  take 
up  the  matter  of  making  a  higher  score  on  any  matter  from  under- 
weight or  dirty  teeth  to  a  better  system  of  lighting,  heating  and 
ventilating  the  school  house  calls  for  leadership  in  which 
teacbers  admit  they  receive  from  their  pupils  as  much  as 
they  give.  This  frank  comradeship  in  action  is  what  makes  this 
sort  of  teaching  a  success,  be  the  pupils  children  or  adults.  Dead 
methods  of  teaching  health  subjects  are  being  discarded  as  rapidly 
as  teachers  can  be  trained  in  the  better  wav.     It  is  not  too  much 


Public  Health  N'urshstg  215 

to  hope  that  with  this  new  broad  avenue  opened  in  public  health 
education  not  only  teachers  of  physical  education,  but  all  students 
of  public  health,  will  be  instracted  in  the  psychologic  method  of 
approach,  or  as  some  prefer  to  call  it,  this  art  of  advertising  and 
selling  health. 

The  general  plan  for  physical  education  for  schools  in  the  State 
as  adopted  by  the  State  Department  of  Education  is  as  follows : 
'•First:  (1)  Individual  health  examination  and  personal  health 
instruction  (medical  inspection)  ; 

(2)  Instruction  concerning  the  care  of  the  body  and  con- 

cerning the  important  facts  of  hygiene  (recitations 
in  hygiene)  ; 

(3)  Physical  exercise  as  a  health  habit,  including  gymna- 

sium, elementary  marching,  and  organized,  super- 
vised play,  recreation  and  athletics. 
"  Second:  (1)  That  the  class  teacher  assist  in  the  individual  health 
examination    and    personal    health   instruction    of 
pupils  through 

(a)  Rapid  inspection  of  all  pupils  at  the  beginning 

of  each  day's  session; 

(b)  Reference  to  the  proper  authority  of  all  chil- 

dren showing  need  of  personal  examination 
and  advice; 

(c)  Appropriate    exercise    and    recreational    pro- 

vision for  all  pupils  reported  by  the  medical 
inspection  as  organically  unfitted  for  regu- 
lar physical  exercise ; 

(d)  The  following  up  of  all  health  advice  that  can 

be  followed  up.     This  assistance  from  the 

regular  class  teacher  is  not  to  take  the  place 

of  the  work   of  the   medical   inspector   or 

school  nurse. 

"Third:   (1)    That  class  instruction  concerning  the  care  of  the 

body  and  the  important  facts  facts  of  hygiene  be 

given  by  the  class  teacher,  except  in  schools  in 

which  special  teachers  are  appointed ; 


216  State  Department  of  Health 

''  (2)   That  the  syllabus  on  physiology  include  such  sub- 
jects as  the  following: 

(a)  General  — 

1  Hygiene  of  the  teacher 

2  Sanitation    of   the    school    room    and 

playground 

3  Hygiene  of  the  janitor 

4  The  use  of  pupils  as  'health  officers' 

or  '  sanitary  inspectors  ' 

(b)  Syllabus  for  elementary  grades,  the  general 

topics  being  cleanliness,  position,  cheer- 
fulness, care  of  the  skin,  care  of  digestion, 
care  of  the  muscles,  care  of  the  eyes,  care 
of  the  ears,  nose,  and  throat,  care  of  the 
teeth,  care  of  the  heart  and  circulation, 
care  of  the  lungs,   care  of  the  nervous 
system. 
"Fourth:  (1)  That  the  instruction  in  physical  exercise  include 
practice  in  such  activities  as  gymnastics,  march- 
ing, play,  recreational  exercise,  and  athletics,  and 
that   reasonable    and    approximately   equivalent 
activities  in  the  home  or  community  life  of  the 
child  be  accepted  as  substitutes  of  this  require- 
ment." 

(The  syllabus  for  Physical  Training  may  be  had  on  application 
to  the  State  Department  of  Education.) 

Physical  Education  in  Part-time  Schools 

The  recently  enacted  law  creating  part-time  schools  in  commu- 
nities of  5,000  inhabitants  or  over,  to  be  administered  by  local 
boards  of  education,  will  insure  to  all  boys  and  girls  between  the 
ages  of  14  and  18  years  who  have  discontinued  attendance  for 
full-time  instruction,  a  continuation  of  this  invigorating  influence. 
This  new  law  creating  part-time  schools  with  state  and  federal  aid 
is  carrying  physical  education  into  the  heart  of  agricultural  and 
industrial  communities.  The  administration  of  the  law  assures 
cooperation  between  agricultural  and  industrial  interests,   pros- 


Public  BQealth  ISTursing  217 

pective  workers  and  local  education  forces  in  the  103  dis- 
tricts in  wliich  the  law  will  become  operative  in  the  autunin 
of  1920.  The  annual  requirement  is  not  less  than  four 
and  not  more  than  eight  hours  weekly  during  36  weeks  of  each 
year,  the  sessions  to  be  held  on  regular  school  days  between  the 
hours  of  8  A.  M.  and  5  p.  m.  It  is  intended  that  not  less  than  one- 
eighth  of  the  time  shall  be  given  to  physical  education  and  hygiene. 
The  type  of  schools  to  be  established  under  this  law  includes  gen- 
eral industrial  schools,  unit-trade  schools,  schools  of  agriculture 
and  schools  in  practical  arts  and  home-making.  To  these  are 
added  evening  schools  for  male  or  female  pupils  over  16  years  of 
age  which  "  shall  provide  instruction  in  subjects  related  to  the 
practical  work  carried  on  in  such  employment."  All  persons, 
firms  or  corporations  employing  minors  between  14  and  18  years 
of  age  are  required  to  permit  such  children  to  attend  these  schools. 
Recent  surveys  made  by  the  Division  of  Agricultural  and  Indus- 
trial Education  indicate  that  manufacturers  are  ready  to  partici- 
pate to  the  fullest  extent  in  making  this  work  fit  the  community 
need. 

Salesmanship  Methods  fok  Health 

In  actual  practice  it  has  been  found  that  the  same  form  of 
health  education  which  appeals  to  children,  viz.,  health  as  a 
by-product  of  games,  sports  and  athletics,  is  the  one  which  appeals 
to  their  elders.  A  group  of  Austrians  in  a  central  'New  York 
village  watched  the  physical  director  of  the  gymnasium  of  the 
industry  employing  such  methods  as  he  coached  fellow-workmen 
at  baseball.  Upon  his  invitation  to  them  to  come  and  take  part  in 
a  game  they  seemed  a  bit  confused,  but  tried  the  game,  changed 
their  efforts  to  something  else,  finally  developed  an  interest  in 
basket  ball  and  made  up  a  team  of  Austrians.  They  spoke  practi- 
cally no  English  at  first,  but  learned  to  use  a  little  English  while 
learning  the  game.  One  evening  after  play  they  proposed  to  the 
director  that  he  should  go  to  their  homes  evenings  and  teach  them 
how  to  speak  and  read  English  "  like  Americans  read."  The 
director  accepted  the  invitation  and  the  first  Americanization  class 
in  that  part  of  the  state  was  begun  as  a  by-product  of  the  gymna- 
sium. 

In  the  same  way  good  health  habits  regarding  food  have 
been  taught  in  the  cafeteria  of  an  industry.    "  Taste  this  pudding 


218  State  Department  of  Health 

before  you  swallow  it ;  if  you  like  it  keep  tasting  before  swallow 
ing ;  we  will  make  things  that  you  like  to  taste  before  swallowing  ' 
if  you  will  tell  us  what  they  ai-e  "  printed  on  a  card  and  served 
with  a  pudding  produces  a  more  satisfactory  reaction  than  an 
appeal  not  to  bolt  the  food.  By  such  methods  health  habits  are 
being  established  among  working  people.  The  cafeteria  creates 
a  demand  for  good  food;  the  athletic  program  establishes  habits 
which  eliminate  the  waste  products;  the  clubs  train  in  citizenship 
and  self-government ;  the  factory  personnel  enjoys  life  and  spreads 
the  contagion  of  happiness  resulting  from  good  habits.  No  negative 
appeal  through  fear  of  malnutrition,  pasty  faces  and  defective 
bodies  would  ever  get  the  hearing  which  this  sort  of  appeal  secures. 
A  country  physician  near  Lake  Ontario  found  a  neighbor's 
motherless  daughter,  a  girl  of  16  years,  with  tuberculosis.  He  set 
about  stimulating  in  her  a  longing  for  a  Ford  runabout  and  then 
induced  her  father  to  buy  it  for  her,  saying  nothing  to  either  of 
them  about  her  disease  as  her  mother  and  only  brother  had  died  of 
it.  The  girl  in  her  runabout  soon  became  the  most  familiar  object 
in  that  countryside.  Before  summer  came  roses  were  in  her 
cheeks,  she  had  taken  on  weight,  and  a  year  after  the  former  exam- 
ination the  physician  could  detect  none  of  the  previous  dreaded 
symptoms. 

CooPERiiTioN  IN  Physical  Education  and  Health  Supervision 

The  response  of  the  public  to  this  development  of  health  through 
play  activities,  and  the  fact  that  ''  the  50,000  teachers  in  the  pub- 
lic schools  are  every  one  expected  to  take  some  part  in  physical 
education,"  has  led  to  special  courses  in  health  work  for  normal 
school  students.  If  health  for  everybody  could  be  captured  with 
a  butterfly  net,  the  situation  would  be  simplified.  But  the  fact  still 
remains  that  not  all  children  are  physically  fit  for  even  nonnal 
play  activities.  For  this  reason  the  school  medical  inspection 
must  take  place  before  physical  training  begins.  Teachers  are 
expected  at  all  times  to  refer  to  the  medical  authority  all  children 
who  appear  to  present  a  departure  from  the  normal.  The  medical 
inspector  is  expected  "  to  establish  the  limitations  within  which 
such  child  may  exercise."  Corrective  exercises  are  developed  to 
meet  individual  needs. 


Public  Health  Nursing  219 

CHAPTER    XVII 
Mental   Hygiene 

In  general  little  time  or  opportunity  has  been  given  in  the 
training  of  nurses  for  instruction  and  supervision  in  mental 
hygiene.  Few  hospitals  provide,  even  temporarily,  for  those  who 
are  mentally  ill.  Most  hospitals  provide  only  medical,  surgical 
and  obstetrical  care  for  acute  or  subacute  cases.  The  tuberculous, 
too  often  considered  hopeless,  have  been  frequently  permitted  to 
die  without  care.  The  feel)le-minded,  epileptic  and  insane  have 
been  hidden  in  many  instances  from  public  notice,  and  in  the 
last  extremity  have  been  confined  in  the  almshouse  or  jail.  The 
reason  for  this  has  doubtless  been  the  lack  of  beds  and  facilities 
and  because  while  speedy  visible  results  follow  medical,  surgical 
and  obstetric  care,  results  from  the  treatment  of  tuberculous  and 
mental  instability  require  many  weeks  or  months.  The  public  is 
beginning  to  understand  that  tendencies  to  theft,  arson  and  mur- 
der may  be  recognized  early,  the  thoughts  of  these  persons 
diverted  into  other  and  normal  channels  and  crime  be  prevented. 
Perhaps  less  generally  understood  is  the  fact  that  much  insanity 
may  be  prevented  if  school  medical  inspectors,  health  officers  and 
public  nurses  are  familiar  with  the  early  symptoms  indicating 
mental  instability,  and  if  cases  with  predisposition  to  psychosis 
and  psychoneurosis  be  given  suitable  early  training  and  treat- 
ment. To  the  public  health  nurse,  whether  serving  a  board  of 
health,  a  board  of  education,  or  however  employed,  will  often  fall 
the  duty  and  opportunity  to  prevent  disaster  to  the  individual 
and  society  by  securing  early  clinic  treatment  for  this  class  of 
cases.  Unfortunate  heredity,  abnormal  surroundings  in  child- 
hood, intoxication  by  alcohol  and  other  poisons  during  the  for- 
mative age,  are  predisposing  causes  of  mental  disorder. 

Dr.   William  Bumham  *  of  Clark  University  has  named   as 
characteristics  of  the  sane  nmid  the  following: 

1  Ability  to  give  attention  to  the  present  situation ; 

2  Orderly  association  of  ideas ; 


•  Transactions   of   the   Fifteenth   International   Congress   on   Hygiene   and 
Demography. 


220  State  Department  of  Health 

3  Normal  reaction  to  feeling  and  emotion 

(a)  first  physical, 

(b)  secondary  associated  psychic; 

4  Inclination  to  proper  alternation  of  periods  of  work  and  rest; 
Conversely  the  following  symptoms  are  characteristic  of  dis- 
ordered mentality: 

1  Inability  to  attend  to  a  present  situation; 

2  Inability  to  associate  ideas; 

3  Failure  in  appropriate  feeling  or  emotion,  reaction,  or  in 
psychic  adjustment  controlling  physical  reaction; 

4  Absence  of  disposition  to  alternate  periods  of  effort  and 
relaxation. 

Dr.  Franlilin  E.  Williams  *  of  the  Massachusetts  Society  for 
Mental  Hygiene  calls  attention  to  two  types  of  personality  which 
are  found  frequently  among  those  who  develop  insanity  of  adole- 
scence and  which  may  be  recognized  during  the  school  period : 

(a)  the  precocious  restless  type,  feverishly  pursuing  knowledge 
and  the  accumulation  of  facts  which  they  gather  but  fail  to  utilize; 

(b)  the  reticent  unsocial  type,  faddish  about  such  details  as 
food,  bath  and  exercise,  irritable  without  cause,  and  sullen  when 


Through  health  supervision  of  children  and  adults  who  show 
these  and  other  symptoms  of  disordered  minds,  through  coopera- 
tion with  educational  and  other  State  authorities,  much  may  be 
accomplished  in  the  prevention  of  insanity.  The  personal  initia- 
tive and  resourcefulness  of  the  public  health  nurse  will  be  the 
determining  factors  in  many  instances  of  the  degree  to  which  dis- 
aster threatening  persons  in  this  class  will  be  obviated.  Such 
persons  should  be  taken  or  sent  to  the  free  clinics  in  mental 
hygiene  which  are  maintained  in  nearly  every  district  of  the  State 
in  connection  with  the  State  hospitals.  The  local  public  health 
nurse  should  write  to  the  State  hospital  for  her  district,  or  to  the 
State  Hospital  Commission  for  information  concerning  the  loca- 
tion of  these  clinics  and  the  name  and  address  of  their  field 
agents.  These  clinics  and  field  agents  for  promoting  mental 
hygiene  have  comparatively  recently  been  greatly  increased  and 


•Transactions   of   the   Fifteenth    International    Congress   on   Hygiene   and 
Demography. 


Public  Health  Nursing  221 

more  generally  em2:)loyed.     Thev  meet  a  great  need  in  the  field 
of  preventive  medicine. 

The  Mental  Defective 
In  studies  conducted  by  the  Eesearch  Department  of  the  Train- 
ing School  for  Mental  Defectives  at  Vineland,  New  Jersey,  b 
per  cent  of  the  children  in  the  first  five  grades  in  school  wert- 
found  defective,  and  15  per  cent  proved  to  be  backward.  (Many 
cases  of  backwardness  may  be  remedied  by  removal  of 
hypertrophied  and  diseased  tonsils,  and  adenoids,  and  by  treat' 
ment  of  defective  hearing,  anemia  and  rickets.*)  Rural  surveys 
made  by  nurses  from  the  State  Department  of  Health  have  shown 
in  every  community  the  presence  of  mental  defectives.  In  certain 
isolated  school  districts  the  majority  of  the  pupils  are  of  low 
grade  mentality.  In  one  district  with  135  school  children  in  7 
schools  a  test  of  their  mentality  showed  6  feeble-minded  and  2 
epileptic.  In  one  township  with  a  population  of  1,127  there  were 
found  5  epileptics  one  of  whom  is  an  imbecile  and  29  feeble- 
minded persons. 

Defective  mentality  is  directly  responsible  for  an  incalculable 
amount  of  poverty,  vice  (including  alcoholism  and  venereal  dis- 
ease) and  crime.  The  public  through  State,  municipal  or  private 
funds  must  pay  the  price  of  this  condition.  Frequently  the  pay- 
ment is  made  through  destruction  of  property  and  economic 
waste.  Statesmen,  educators,  and  other  social  agents  are  seeking 
to  give  adequate  care  and  supervision  to  this  class  of  persons. 
Adequate  care  involves  educational  supervision,  and  training  with 
custodial  care  when  necessary;  and  through  colonization,  pre- 
vention  of  reproduction  of  their  kind,  while  allowing  the  largest 
possible  amount  of  individual  freedom  and  usefulness.  To 
accomplish  this  several  State  institutions  have  been  created  for 
epileptics,  misdemeanants,  delinquents  and  other  children  and 
adults  of  defective  mentality.  The  school  nurse  should  cooperate 
with  local  agencies  to  secure  the  fullest  possible  education  of  these 
children,  bearing  in  mind,  however,  that  since  defective  mentality 
is  incurable,  the  nurse's  work  generally  will  not  only  be  economi- 
cally more  efficient,  but  also  produce  a  better  citizenship  if  per- 
manent  custodial  care   can  be   provided   for  these   unfortunate 


Dr.  H.  H.  Drysdale,  Cleveland  Medical  Journal,  Vol.  IV,  No.  X. 


222  State  Department  of  Health 

persons.  It  costs  the  State  less  than  $175  per  year  to  care  ade- 
quately for  its  mental  defectives.  What  it  costs  to  care  for  them 
inefficiently  in  the  home  can  not  be  computed,  the  toll  being  ex- 
acted not  only  in  cash,  but  also  in  suffering  in  which  those  not 
mentally  defective  are  also  involved. 

Paragraph  68,  State  Charities  Law,  provides  that  feeble-minded 
children  may  be  received  into  a  State  institution  for  the  feeble- 
minded upon  the  official  application  of  a  county  superintendent 
of  the  poor  or  the  commissioner  of  charity  of  a  city,  and  that  in 
snch  admissions  preference  shall  be  given  to  indigent  children. 

Paragraph  94,  Art.  7  of  the  State  Charities  Law  provides  that 
"  superintendents  of  the  poor  of  the  various  counties  of  the  state 
may  commit  to  an  asylum  for  the  custody,  maintenance,  training 
and  treatment  of  such  persons  "  if  vacancies  exist  therein,  feeble- 
minded persons  and  idiots  in  their  respective  counties.  Insane 
idiots  and  epileptics  are,  however,  sent  to  insane  hospitals.  The 
maintenance  of  all  such  persons  becomes  a  charge  upon  the  State 
if  the  parents  or  guardians  are  unable  to  pay  for  same. 

Paragraph  461,  Art.  22  of  the  State  Charities  Law  provides 
that  "  on  application  of  a  parent,  guardian,  friend,  or  relative, 
or  of  any  poor  law  official,  or  of  any  probation  or  parole  officer, 
or  of  any  superintendent  or  principal  of  schools,"  it  shall  be  the 
duty  of  the  judge  of  a  court  of  record  to  set  a  date  of  hearing  to 
determine  the  mental  status  of  the  alleged  feeble-minded  child. 
If  it  appears  to  the  judge  that  it  is  to  the  best  interest  of  the 
individual  and  the  community  that  the  person  shall  be  committed 
to  a  public  institution  for  the  care  of  such  persons  the  judge  may 
make  the  commitment. 

The  State  Commission  for  the  Focblc-minded,  the  State  Board 
of  Charities  or  the  State  Charities  Aid  Association  should  be 
called  upon  for  advice  whenever  the  nurse  does  not  know  how 
to  proceed  in  dealing  with  this  class  of  defect.  Many  counties 
have  Agents  for  Dependent  Children  and  Children's  Aid  Societies 
to  handle  such  cases. 

Often  tuberculous  children  and  parents  are  also  defective  men- 
tally. The  tuberculous  condition  should  not  be  the  one  first  con- 
sidered in  such  cases,  for  expense  involved  in  caring  for  these 
children  in  open  air  schools  is  often  wasted,  the  children  relapsing 


Public  Health  Nursing  223 

within  a  few  weeks  after  returning  to  their  homes.  In  all  such 
cases  from  a  purely  economic  standpoint,  and  surely  for  the 
permanent  welfare  of  the  child,  counsel  should  be  sought  from  a 
psychiatrist,  and  every  effort  made  to  induce  parents  to  consent  to 
the  treatment  prescribed.  There  is  a  Stat©  Colony  for  the  Care  of 
Epileptics.  Any  moral  pervert,  habitual  plotter  of  mischief,  or 
otherwise  delinquent  child  should  be  regarded  by  the  nurse  as 
probably  mentally  defective,  and  should  be  taken  to  a  psychiatrist 
for  examination.  The  counsel  of  the  State  Medical  School  In- 
spector of  the  State  Department  of  Education,  or  of  the  'New 
York  State  Commission  for  the  Feeble-minded,  should  be  sought 
if  a  proper  examination  for  diagnosis  can  not  be  locally  provided. 
Quite  frequently  there  will  come  to  the  attention  of  the  public 
health  nurse  instances  where  minors  who  have  been  in  special 
classes  for  the  subnormal  have  left  school  at  the  earliest  allowable 
date,  and  lacking  the  guidance  which  they  had  in  school,  they  have 
drifted  into  back  eddies  of  the  community,  there  to  be  a  source  of 
positive  harm  to  others.  The  fact  that  at  the  present  time  there 
is  inadequate  institutional  space  provided  for  these  unfortunate 
children  should  not  deter  the  nurse  from  taking  up  each  case  with 
the  iState  Commission  for  the  Feeble-minded.  Frequently  pro- 
vision can  be  made  to  safeguard  the  child  and  the  public.  More- 
over adequate  provision  can  not  be  expected  if  actual  needs  for 
care  of  this  class  of  persons  are  not  known. 


224  State  Departmiint  of  Health 


CHAPTER  XVni 
Hygiene  of  Home  and  Workshop 

To  improve  the  immediate  onvironment  of  persons  in  their 
homes'  and  places  of  daily  occupation  is  one  of  the  most  important 
objects  of  sanitary  supervision.  Bad  housing  conditions,  over- 
crowding, filthy  and  dirty  habits,  and  lack  of  proper  light  and 
ventilation,  reduce  individual  resistance  and  thus  favor  the  trans- 
mission of  all  kinds  of  communicable  disease,  especially  tuber- 
culosis. At  the  same  time  improvement  of  such  conditions  is 
often  one  of  the  most  difficult  problems  vs^hich  health  authorities 
have  to  meet,  because  they  are  interwoven  not  only  with  estab- 
lished structural  defects  in  buildings,  but  also  with  confirmed 
habits  of  living  and  indifference  of  the  people  themselves.  Hence 
this  problem  will  require  for  its  solution  a  persistent  campaign  of 
popular  education,  the  result  of  which,  while  far  reaching  in  its 
effects,  must  necessarily  be  slow. 

Housing 

The  teiTQ  "  housing  "  broadly  considered,  properly  includes  all 
conditions  in  ordinary  dwelling  houses,  in  factories,  schools,  public 
buildings,  and  structures  of  all  kinds;  but  it  is  usually  applied 
more  particularly  to  dwelling  houses  and  the  conditions  found 
inside  of  the  home  in  contradistinction  to  conditions  outside  of  or 
surrounding  the  dwelling. 

In  dealing  with  housing  conditions  such  questions  are  to  be 
considered  as  the  hygiene  of  the  home,  —  how  people  live,  whether 
in  a  cleanly  or  uncleanly  manner ;  the  size  of  the  dwelling  quarters 
and  the  number  of  people  occupying  a  room;  whether  the  house 
is  out  of  repair  or  lacks  windows;  and  whether  it  has  proper  heat- 
ing facilities,  protection  against  fire,  etc.  In  all  these  conditions 
the  public  health  nurse  can  do  a  great  deal  through  helping  to 
raise  the  standard  of  living  by  means-  of  popular  instructions  in 
the  home.  The  following  are  the  chief  unhygienic  conditions  to 
be  observed : 

1  Overcrowding.  CK^ercrowding  offers  increased  opportunities 
for  transmission  of  disease  by  direct  contact  and  favors  uncleanli- 


Public  Health  iSTi: using  2:25 

uess,  bad  ventilation  and  other  factors  which  are  conducive  to 
indirect  transmission  of  infection.  Coniniuuitj  congestion,  or  the 
overcrowding  of  dwellings  on  a  limited  area  of  land,  as  with 
tenement  houses,  cuts  off  light  and  air,  and  leads  to  other  dis- 
advantageous conditions.  Family  congestion,  or  room  overcrowd- 
ing, is  more  important  in  its  effect  upon  health.  The  size 
of  rooms  for  dwellings  is  somewhat  of  an  economic  question  and 
it?  regulation  is  an  exceedingly  difficult  administrative  problem, 
but  health  authorities  have  a  clear  duty  to  perform  in  restricting 
the  number  of  persons  who  may  occupy  a  certain  air  space,  in 
making  regulations  regarding  the  constiiiction  of  new  buldings 
and  in  requiring  necessary  alterations  of  old  ones.  Theoretically, 
the  rooms  should  be  large  enough  to  allow  the  air  to  be  replaced 
two  or  three  times  an  hour  without  causing  perceptible  drafts. 
This  would  require  a  minimal  air  space  of  from  700  to  1,000 
cubic  feet  per  person.  Very  few  rooms  in  ordinary  dwelling 
houses,  however,  are  found  with  more  than  600  cubic  feet  of  air 
space  per  person,  and  many  with  scarcely  half  as  much  as  this. 
But  however  large  the  space  may  be,  the  air  will  become  impure 
unless  fresh  air  is  allowed  to  circulate,  and  however  small  the 
space  the  air  may  be  kept  reasonably  pure  by  sufficient  circula- 
tion. Movement  of  the  air  is  therefore  of  greater  importance 
than  the  size  of  the  room. 

•2  I  n cleanliness.  Uncleanliness  is  even  more  undesirable  than 
overc^o^^■ding  as  a  factor  in  disseminating  disease  by  direct  con- 
tact. Moreover,  both  directly  and  through  their  physiological 
action,  personal  uncleanliness  and  unclean  conditions  in  them- 
selves undoubtedly  exert  a  depressing  effect  on  human  beings, 
esyjecially  upon  children  and  sensitive  or  delicate  adults  and 
thus  also  act  as  contributing  causes  of  disease. 

3  Lack  of  proper  ventilation,  light,  etc.  Under  this  head  may 
be  included  a  number  of  remaining  conditions  referring  chiefly 
to  ventilation.  The  lack  of  light  has  more  of  an  indirect  than  a 
direct  effect  in  favoring  uncleanliness;  darkness  being  usually 
associated  with  dirt,  dampness,  and  faulty  ventilation.  Light  is  for 
this  reason  as  necessary  to  health  as  cleanliness  and  fresh  air. 
Light,  especially  direct  sunlight,  is  a  valuable  germicide.  A  room 
or  dwejimg  into  which  the  sun  never  shines  can  not  be  health- 
^  8 


226  State  Department  of  Health 

ful  and  those  who  inhabit  dark,  damp  apartments  soon  become 
pale  and  sickly,  like  plants  that  are  kept  in  a  cellar. 

A  dwelling  in  need  of  repair  is  not  always  an  indication  of 
poverty,  but  is  often  evidence  of  the  low  standard  of  living  of  its 
occupants.  Such  houses  are  not  infrequently  centers  of  disease 
and  infection. 

4  Plumhing  inspection.  Modern  sanitary  science  does  not  place 
much  importance  upon  plumbing  inspection  from  the  health 
standpoint  except  insofar  as  it  relates  to  human  excreta. 
Sewer  gas,  once  a  hygienic  bugaboo,  is  no  longer  considered  really 
dangerous,  however  disagreeable  its  odors  may  be.  Nevertheless, 
such  odors  should  not  exist  as  they  are  usually  an  evidence  of 
imperfect  plumbing  fixtures.  The  public  health  nurse  should 
therefore  look  for  any  evidences  of  leakage  around  such  fixtures, 
and  should  note  general  conditions  and  whether  proper  provision 
is  made  for  the  disposal  of  the  wastes. 

5  Types  of  dwellings.     The  principal  types  of  dwellings  are: 

(1)  The  one-family  house,  which  is  the  ideal  dwelling  from  a 
sanitary  point  of  view,  especially  if  built  detached. 

(2)  The  two-family  house,  of  which  there  are  two  kinds:  (a) 
the  double  house  with  a  party  wall  or  division  in  the  middle,  with 
separate  entrances  on  each  side,  each  family  occupying  one-half 
the  house;  (b)  the  double  house  in  which  one  family  occupies  the 
ground  floor  and  possibly  the  basement,  and  another  family  occu- 
pies a  second  and  sometimes  a  third  floor,  with  separate  entrances 
for  each  family.  Such  dwellings  may  be  quite  as  satisfactory  from 
a  sanitary  standpoint  as  one-family  houses. 

(3)  Tenement  houses.  Dwellings  are  usually  classed  as  tene- 
ment houses  when  more  than  two  families  live  independently  but 
share  common  stairs  or  hallways.  The  tenement  house  exists  in 
all  large  cities  in  this  country.  The  suburban  dwelling  may 
eventually  be  so  developed  and  cheapened  in  some  localities  as  to 
do  away,  partially  at  least,  with  the  groat  demand  for  tcnonicnts. 
Tenement  houses,  however,  should  be  under  the  conti-ol  of  health 
and  housing  authorities,  (like  the  Tenement  House  Commission 
in  this  State)  which  should  regulate  their  construction  and  care, 
and  the  building  of  new  tenements  should  be  discouraged  in  those 
places  when  there  is-  no  economic  need  for  their  existence. 


Public  Health  Nursing  227 

The  housing  problem,  however,  is  not  confined  to  any  one  type 
of  dwelling.  The  conditions  found  in  houses  technically  classed 
as  one  or  two-family  houses,  are  often  quite  as  bad  as  those  found 
in  tenements.  These  conditions  may  be  due  to  faulty  construction 
or  care  by  the  landlord,  or  to  the  crowding  of  more  than  one 
family  into  a  "  one-family  "  house,  or  to  more  than  two  fami- 
lies into  a  "  two-family  "  house  (especially  in  growing  industrial 
communities).  There  is  the  lodger  problem  to  contend  with 
everywhere  in  all  types  of  dwellings. 

(4)  Public  buildings.  Public  buildings  such  as  schools, 
churches,  theatres,  moving  picture  shows,  factories  and  workshops, 
public  baths,  court  houses  and  other  municipal  and  state  build- 
ings, require  attention  chiefly  in  relation  to  cleanliness,  lighting 
and  ventilation.  Of  these  ventilation  is  the  most  important,  for 
in  buildings  of  this  class  proper  ventilation  is  the  exception  rather 
than  the  rule.  Owing  to  the  fact  that  great  numbers  of  people 
spend  many  hours  of  each  day  in  such  places,  this  is  a  distinctly 
important  field  of  work  for  the  public  health  nurse  and  for  other 
public  health  inspectors. 

Ventilation 

Ventilation  is  commonly  supposed  to  be  a  very  simple  matter, 
viz.,  to  furnish  a  continuous  stream  of  fresh  air  from  the  atmos- 
phere outside  of  the  house  to  replace  that  which  is  constantly 
being  vitiated  inside.  But  to  do  this  under  the  artificial  condi- 
tions in  which  people  live  and  work  is  often  extremely  diSicult, 
if  not  sometimes  impossible. 

Ventilation  to  be  satisfactory  must  serve  a  number  of  purposes 
and  comply  with  a  number  of  conditions :  ( 1 )  It  must  bring  pure 
air  from  without  in  order  to  dilute  the  products  of  respiration 
as  well  as  the  other  sources  of  vitiation;  (2)  it  must  maintain 
the  air  within  the  room  at  a  proper  temperature  and  humidity, 
and  further,  must  keep  the  air  of  the  room  in  gentle,  continuous 
motion;  (3)  it  must  remove  the  gases,  odors,  bacteria,  dust  and 
other  substances  that  contaminate  the  air  of  inclosed  spaces,  aiid 
the  impurities  produced  by  the  burning  of  ^as.  caxidies,  iainpg 


228  State  Department  of  Health 

and  other  sources  of  illummation.  The  purpose  of  ventilation, 
in  other  words,  is  not  so  much  to  bring  out-door  conditions 
indoors  as  to  adapt  indoor  conditions  to  indoor  life,  wiiich  is 
necessary  in  order  to  perform  the  kind  of  work  which  can  not, 
as-  a  rule,  be  effectively  carried  on  outdoors,  involving  quiet 
and  protection  from  sudden  changes  and  extremes  of  tempera- 
ture, etc. 

The  mechanical  problem  of  regulating  the  temperature  and 
humidity  within  narrow  limits  and  of  furnishing  definite  quan- 
tities of  fresh,  moving  air  is  not  difficult  for  the  ventilating  engi- 
neer to  solve,  but  to  maintain  those  conditions  necessitates  the 
shutting  of  doors'  and  windows.  The  conditions  inside  and  out- 
side of  the  room  to  be  ventilated  are  not  constant,  depending  upon 
the  force  and  direction  of  the  wind,  the  changes  of  outdoor  tem- 
perature and  to  less  extent,  the  air  movements  within  the  room. 
Allowance  for  these  conditions  must  therefore  be  made,  which  can 
not  be  done  with  open  windows  and  doors  by  any  system  of 
ventilation. 

The  efficiency  of  ventilation  is  measured  by  the  results  obtained 
at  the  breathing  zone.  Provided  the  heated,  moistened  and 
vitiated  air  which  surrounds  us  is  constantly  removed  and 
replaced  with  a  fresh  supply  properly  conditioned,  it  does  not 
matter  what  the  air  is  near  the  ceiling.  Moreover,  the  air  brought 
into  the  room  must  be  clean,  not  smoky,  dusty  or  laden  with  bac- 
teria, or  contaminated  with  gases  or  odors  if  the  ventilation 
is  to  be  satisfactory.  The  sources  of  the  air,  for  this  reason,  must 
always  be  considered  as  of  great  importance.  Ventilation  and 
heating  are  also  closely  related.  Clean  air  in  motion  and  of  proper 
temperature  and  htimidity  is  necessary  to  indoor  comfort.  Satis- 
factory ventilation  thus  not  only  takes  into  consideration  the 
physical  condition  of  the  air,  but  also  demands  a  generotis  supply 
of  fresh  air. 

The  inhabitants  of  climates  like  ours  are  apt  to  live  under 
artificial  conditions  in  over-heated  houses,  and  often  complain  of 
poor  ventilation,  regardless  of  whether  the  air  supply  is  large  or 
small.  Our  dwelling  houses  are  usually  constructed  without  any 
regard  to  ventilation,  which  requires  just  as  much  care  and  fore- 


Public  Health  litjRsiXG  229 

thought  as  the  system  of  heating  the  house  or  supplying  it  with 
watex,  gas  or  electricity,  or  the  proper  disposal  of  wastes.  There- 
fore, whatever  system  of  ventilation  is  employed  in  a  house,  the 
public  hoalth  nurse  should,  if  possible,  see  that  sunshine  is  ad- 
mitted and  that  the  rooms  are  frequently  flushed  with  fresh  air. 
When  a  room  smells  stuffy  and  close  it  may  be  taken  as  a  fairly 
reliable  index  that  the  air  is  vitiated.  The  odors  observed  upon 
entering  a  room  from  the  outside  fresh  air  often  furnish  better 
evidence  of  imperfect  ventilation  than  laboratory  tests. 

The  size  and  shape  of  the  room  are  very  important  factors  in 
any  system  of  ventilation.  The  minimal  space  should  be  about 
one-third  the  quantity  of  air  required  per  hour ;  that  is,  from  YOO 
to  1,000  cubic  feet  per  person.  The  amount  of  space  naturally 
varies'  with  dwellings,  factories,  schools,  prisons,  hospitals,  etc., 
also  with  the  length  of  time  the  room  is  occupied  and  the  nature 
of  the  work  there  carried  on.  But  the  regulation  of  space  is  by 
itself  of  little  value,  unless  there  is  movement  of  air.  A  small 
space  is  sufficient  if  properly  ventilated ;  a  large  space  inadequate 
if  improperly  ventilated.  ,I^or  is  it  the  air  space  of  the  room  alone 
that  influences  ventilation ;  a  lofty  room  is  not  necessarily  an  airy 
room,  for  a  stratum  of  warm  vitiated  air  soon  occupies  the  upper 
portion  of  such  space,  and,  so  far  as  good  air  is  concerned,  has  the 
effect  of  lowering  the  effective  height  of  the  ceiling  to  the  top  of 
the  window  or  door.  Floor  sjjace  is  much  more  important  than 
height.  According  to  Harrington,  when  the  allowance  is  only  500 
cubic  feet  per  person  the  floor  space  should  be  42  sq.  ft.  (8^^x53/^). 
Ordinarily  9  ft.  is  high  enough  for  the  ceilings  of  private  dwell- 
ings, and  12  ft.  for  schools,  etc. 

Inlets  and  outlets  should  be  provided,  whatever  system  of  ven- 
tilation is  employed ;  proper  inlets  for  the  fresh  air  and  outlets  for 
the  vitiated  air.  Whether  the  air  is  to  be  admitted  near  the  floor 
and  taken  out  near  the  ceiling  or  vice  versa  is  a  question  much 
discussed  among  ventilating  engineers.  Perhaps  the  best  arrange- 
ment is  to  have  the  inlet  above  and  the  outlet  below,  both  on  the 
same  side  of  an  inner  wall.  Y*^ntilating  ducts  usually  extend  up 
the  walls  of  the  building  through  the  roof,  and  should  be  hooded 
at  the  top. 


230  State  Department  of  Health 

Natural  ventilation  is  that  which  depends  upon  openings  such 
as  doors  and  windows,  and  upon  the  air  that  comes  through  the 
pores  of  plaster,  brick  and  stone,  through  floors  and  ceilings, 
and  the  cracks  and  crevices  about  window  frames,  etc.  N"atural 
ventilation  is  better  in  winter  than  in  summer  owing  to  the  greater 
differences  in  temperature.  On  a  hot,  calm  day  it  may  amount  to 
nothing.  If  there  is  too  much  moisture  in  the  air  of  rooms  it 
settles  upon  the  pores  of  building  materials.  Eain  has  a  similar 
effect.  Ventilation  is  also  impeded  by  oil  and  paint  and  by  wall 
paper.  Excessive  near])y  foliage  and  narrow  streets  with  high 
buildings  act  as  outside  obstacles. 

J^atural  ventilation  may  be  favored  by  simple  devices'  which 
may  be  placed  at  the  top  or  bottom  of  windows  to  allow  the 
entrance  of  fresh  air  and  the  exit  of  vitiated  air. 

Mechanical  veniiUdion  or  ''  artificial "  ventilation  depends 
upon  one  of  the  three  following  methods:  (1)  j^lenum  system 
which  consists  in  the  mechanical  propulsion  of  air  into  the  room ; 
(2)  vacuum  system,  which  consists  of  the  mechanical  extraction 
of  the  air  out  of  the  room;  (3)  a  combination  of  the  plenum 
and  vacuum  systems. 

Air  may  be  forced  into  a  room  either  by  means  of  a  wai-ming 
apparatus  or  by  mechanically  propelling  the  air  by  means  of 
rotary  fans  or  "  blowers."  Every  heating  apparatus  acts  also  as 
a  ventilator,  especially  hot  air  furnaces  and  the  direct-indirect 
system  in  use  with  hot  air  or  steam  pipes.  Open  firepbiees,  stoves, 
etc.,  are  also  good  ventilators,  if  properly  constructed.  The  dis- 
advantages of  the  mechajiical  systems  of  ventilation  are  that  they 
are  expensive  to  install  and  maintain,  and  furthermore,  they  ai*e 
designed  to  work  only  when  all  the  doors  and  windows  are  kept 
closed.  On  the  other  hand,  they  are  effective  in  all  kinds  of 
weather  and  require  less  space  than  natural  ventilation. 

Heating 

Heating  aiul  xcntilation  <;()  liand  in  hand,  so  nnie]i  so  that  if 
ventihition  is  overdone,  it  causes  unnecessary  expense  in  heating. 

Many  of  our  houses  are  overheated  with  abnormally  dry  air  in 
the  winter  time.  This  causes  excessive  evaporation  from  the  skin, 
giving  rise  to  a  sensation  of  chilliness.     Tt  also  causes  at  times 


Public  Health  Nursing 


231 


disposition  to  colds  and  other  reppiratory  infections.  Warm  dry 
air  does  not  give  the  same  sense  of  warmth  and  comfort  as  does  a 
cooler  moist  air.  Air  at  62°  to  65°  F.  and  a  relative  humidity 
of  70  per  cent  feels  warmer  than  air  at  70°  to  72°  F.  and  a  rela- 
tive humidity  of  50  per  cent.*  Furnace,  hot  water,  and  steam 
heat  tend  to  dry  the  air.  Hence  our  houses  and  offices  have  to 
he  overheated  to  make  them  comfortable  unless  some  form  of 
ventilating  apparatus  is  used. 

Both  thermometer  and  hygrometer  should  be  provided  —  in 
fact  the  hygrometer  to  give  the  humidity  readings  is  quite  as 
important  an  instiTiment  to  have  in  the  home  or  workshop  as  is 
the  thermometer  to  indicate  the  temperature. f 

The  chief  methods  of  heating  are:  (1)  Open  fireplaces;  (2) 
stoves;  (3)  hot  air;  (4)  hot  water  or  steam;  and  (5)  electricity. 
The  control  of  the  temperature  of  a  building  is  of  more  impor- 
tance tlian  the  system  of  heating  used. 

Open  fires  heat  mainly  through  direct  radiation,  and  have  the 
advantage  of  being  cheerful  and  serve  as  good  ventilators,  but 
they  are  wasteful  and  give  a  very  uneven  temperature  if 
depended  on  alone  as  a  source  of  heat. 

FranJclin  stoves  consist  of  coal  fires  in  a  cast-iron  stove  with  a 
pipe  to  carry  off  the  products  of  combustion.  They  stand  free  in 
the  room,  and  are  very  efficient  as  a  source  of  heat  but  the  heating 
is  unequal.  Such  stoves  when  red  hot  are  believed  to  allow 
carbon  monoxide  to  pass  through  the  cast-iron. 

Open  gas  heafers  without  ilucs  to  carry  off  the  products  of  com- 
bustion are  bad  from  a  sanitary  standpoint.  Such  heaters  may 
contaminate  the  air  with  carbon  monoxide  from  leakage  or  from 
unconsumed  gas ;  they  also  give  off  carbonic  acid  gas  and  other 
products.  Open  heaters  burning  oil  are  less  objectionable  than 
gas  heaters. 


*  The  Chicago 
indoor  humiditv 


Joard  of  Health  published  a  table  designed  to  show  desirable 
in  the  American  home  as  follows: 


Degrees  of  temperature 

60°  F. 

66°  F. 

68°  F. 

79°  F. 
.34-40 

72°  F. 

Per  cent  relative  humidity 

64-74 

50-54 

40-48 

30-34 

tAniierican  Journal  of  Public  Health.     Vol.  VI,  No.  G. 


232  State  Department  of  Health 

Hot  air  furnaces  consist  of  coal  stoves  which  heat  a  series  of 
tubes  or  plates  in  the  dome  over  which  air  from  the  outside  is 
passed.  It  comes  in  contact  with  the  hot  surfaces  and  is  then 
conducted  by  a  series  of  flues  into  the  rooms  of  the  house.  A  liot 
air  furnace  of  this  kind  constantly  caiTies  fresh  air  into  the  house, 
and  is,  therefore,  a  veiy  efficient  system  of  ventilation.  The 
objections  to  the  hot  air  furnace  are  that  the  air  becomes  exces- 
sively dry  and  frequently  is  "  burned  "  in  passing  over  the  heated 
surfaces  in  the  dome,  thus  causing  an  unpleasant  odor  in  the 
house.  If  sufficiently  large  pans  of  water  are  placed  in  the  fur- 
nace to  allow  adequate  evaporation  of  moisture,  this  dryness  may 
be  overcome,  but  the  water  pans  provided  are  frequently 
inadequate. 

Hot  ivater  and  steam  systems  are  a  simple  and  effective  means  of 
heating  buildings.  The  hot  water  system  is  especially  ai:>plicable 
to  small  buildings  and  steam  pipes  to  large  buildings.  The 
former  is  the  more  expensive  to  install  on  account  of  the 
greater  amount  of  radiation  required,  but  requires  less  fuel  and 
is  more  easily  regulated  than  a  steam  system  which  has  a  tend- 
ency to  overheat.  If  the  hot  water  pipes  or  steam  coils  are 
exposed  directly  in  the  room,  the  system  is  known  as  "  direct." 
If  the  pipes  are  placed  in  a  special  box  where  the  air  from  the 
outside  is  heated  and  then  conducted  into  the  room,  it  is  call(\i 
the  "  direct-indirect  "  system.  In  l)oth  of  these  systems  the  air 
is  abnormally  dried  but  not  to  such  a  degree  as  with  the  hot  air 
furnace. 

Electric  heating  is  clean  and  easily  regulated,  but  expensive. 
It  has  the  disadvantage  of  being  insufficient  as  a  ventilating 
device. 

Cooling  of  rooms  has  untilrecontlyreceived  very  little  attention, 
but  it  is  quite  as  practicable  to  cool  rooms  as  to  heat  them  and 
sometimes  as  important  to  health.  The  principle  of  all  cooling 
devices  depends  upon  the  fact  that  when  a  fluid  is  transformed  to 
its  gaseous  state  it  absorbs  latent  heat  which  is  taken  from  the  sur- 
rounding objects,  aud  those,  therefore,  become  correspondingly 
cool.  Ammonia  gas  is  now  almost  universally  used  in  freezing 
machines  for  cooling  refrigerators,  cold  storage  rooms,  etc.,  in  this 
way.  Humidifiers  and  air  washers  are  also  used  to  cool  rooms 
and  Iniildings.     A  simple  method  of  cooling  a  room  is  to  hang  a 


Public  Health  Kuesing  283 

sheet,  about  a  yard  or  more  wide,  near  the  ceiling  and  keep  it  con- 
stantly moistened  by  a  stream  of  water  flowing  over  it.  Evapora- 
tion is  brought  about  by  blowing  air  on  the  wet  sheet  ]>y  meaus  of 
an  electric  fan. 

Lighting 

Provisions  should  1)6  made  in  all  dwelling  houses  for  an  abun- 
dant supply  of  sunlight.  Every  room  should  have,  if  possible, 
at  least  one  window  receiving  the  sun  during  some  portion  of  the 
day.  It  is  not  sufficient  to  give  an  ample  window-space,  which 
should  be  in  proportion  of  one  to  five  or  six  of  floor  space,  but 
the  immediate  surroundings  of  the  house  must  be  taken  into 
account.  Thus,  close  proximity  of  other  buildings  or  of  trees  may 
prevent  sufficient  light  entering  a  room,  although  the  window- 
space  may  be  in  excess  of  that  required  under  ordinary  circum- 
stances. Light  is  as  necessary  to  health  as  fresh  air.  "  Where 
the  sun  cannot  enter,  the  doctor  does,"  is  an  old  Italian  proverb. 
"  The  man  who  plants  a  tree  in  front  of  his  house  begins  to  dig 
his  own  grave,"  is  another  saying. 

Xot  only  living  rooms  and  dwellings,  but  churches,  schools,  lec- 
ture halls,  courts  of  justice,  and  all  places  where  many  people 
congregate,  must  have  plenty  of  light  as  well  as  good  ventilation, 
in  order  to  be  healthful. 

Pecent  investigations  have  shown  that  coal-gas  or  its  products 
in  indoor  air  are  dangerous  even  when  existing  in  very  small 
quantities.  This  danger  has  increased  with  the  introduction  of 
the  more  modern  water  gas,  which  contains  30  per  cent  of  carbon 
monoxide.  Illuminating  gas  may  readily  pass  from  a  broken  gas 
main  through  the  soil  into  the  cellar  of  a  house;  this  is  aided 
by  the  suction  and  j)umping  action  of  the  heating  apparatus  in 
the  cellar.  In  passing  through  the  soil  the  gas  may  be  robbed 
of  its  characteristic  odor,  thus  rendering  it  less  easy  of  detection. 
Again,  the  gas  pipes  and  fixtures  in  a  dwelling  may  become  leaky 
from  a  faulty  stopcock,  from  rubber  tubing  used  for  drop 
lights,  etc.  For  this  reason,  one  should  note  the  condition  of  the 
gas  piping  and  fixtures  especially  in  tenements,  but  also  in  one 
and  two-family  houses  and  public  buildings.  Attention  should 
be  paid  to  possible  leaks  in  entering  mains  underneath  houses, 
from  which  gas  may  arise  and  permeate  the  dwelling,  unperceived 


234  State  Departmext  of  Health 

or  disregarded  by  the  tenants.  Such  inspections  require  no 
apparatus  beyond  a  fairly  keen  sense  of  smell,  and  can  be  readily 
made  during  a  plumbing  inspection.  Illuminating  gas  is  much 
more  dangerous  than  sewer  gas. 

The  electric  light  is  probably  open  to  less  objections  on  the 
ground  of  danger  than  any  other  of  the  illuminating  systems  men- 
tioned. The  advantages  of  the  incandescent  light,  besides  the 
brilliant  white  light  it  gives,  are  that  it  is  steady  and  does  not 
produce  much  heat,  and  that  it  does  not  pollute  the  air  with  car- 
bon dioxide  and  other  products  of  combustion. 

Industrial  Hygiene 

Industrial  hygiene  or  hygiene  of  the  work  shop  is  one  of  the 
most  important  subjects  in  public  health,  as  it  deals  with  the 
health  and  welfare  of  a  large  portion  of  the  population. 

In  ISTew  York  State  the  field  of  industrial  hygiene  is  assigned 
to  the  Industrial  Commission  for  investigation  and  protective 
regulation,  with  definite  administrative  machineiy  specified  for 
the  purpose,  as  indicated  by  the  following  sections  of  the  Labor 
Law : 

ARTICLE   3 

§  4(K  hulustrial  commission  created. —  There  shall  l>o  a 
depai-tment  of  labor,  the  head  of  which  shall  be  the  industrial 
commission.  The  commission  shall  consist  of  five  commis- 
sioners appointed  by  the  governor  by  and  with  the  advice 
and  consent  of  the  senate,  one  of  which  shall  be  designated 
by  the  governor  as  chaimnan. 

§  42.  Bureaus. —  The  department  of  labor  shall  have  the 
following  bureaus:  inspection;  statistics  and  information; 
mediation  and  arbitration;  industries  .  and  immigration; 
employment;  workmen's  compensation;  women  in  industry; 
and  such  other  bureaus  as  the  conunission  may  deem 
nccessiiiy,  siilijcct  to  apj^ropriation  by  the  legislature.  Each 
bureau  and  division  of  the  department  and  the  persons  in 
charge  thereof  shall  be  subject  to  the  su|>eiwision  and  direc- 
ti(m  of  the  conunission  and  of  any  connnissioner  duly  desig- 
luitod  to  su])ervise  the  work  of  such  bureau,  and  in  addition 
to  their  respective  duties,  as  prescribofl  l)y  this  chapter  shall 
perform  sncli  other  dnties  as  may  be  assigned  to  them  l)y  the 
commission. 


Public  Health  Nursing  235 

§  51-a.  Rules  and  regulations. —  (1)  The  commission 
shall  have  power  to  make,  amend  and,  repeal  niles  and  regula- 
tions for  carrying  into  effect  the  provisions  of  this  chapter, 
applying  such  provisions  to  specific  conditions  and  prescrib- 
ing means,  methods  and  practices  to  effectuate  such  provi- 
sion. 

(2)  The  commission  shall  have  power  to  make,  amend  and 
repeal  i-ules  and  regulations  for  proper  sanitation  in  all  places 
to  which  this  chapter  applies,  and  for  guarding  against  and 
minimizing  fire  hazards,  personal  injuries  and  diseases  in 
all  places  to  which  this  chapter  applies,  with  respect  to 

a.  The  construction,  alteration,  equipment  and  mainte- 
nance of  all  such  places,  including  the  conversion  of  struc- 
tures into  factories,  factory  buildings  and  mercantile  estab- 
lishments ; 

b.  The  arrangement  and  guarding  of  machinery  and  the 
storing  and  keeping  of  property  and  articles ; 

c.  The  places  where  and  the  methods  and  operation  by 
which  trades  and  occupations  may  be  conducted,  and  the  con- 
duct of  employers,  employes  and  other  persons ; 

It  being  the  policy  and  intent  of  this  chapter  that  all  places 
to  which  it  applies  shall  be  so  constructed,  equipped,  arranged, 
operated  and  conducted  in  all  respects  as  to  provide  reason- 
able and  adequate  protection  to  the  lives,  health  and  safety 
of  all  persons  employed  therein,  and  frequenting  the  same, 
and  that  the  commission  shall  from  time  to  time  make  such 
niles  and  regulations  as  will  effectuate  such  policy  and  intent. 

(3)  Whenever  the  commission  finds  that  any  industry, 
trade,  occupation  or  process  involves  such  elements  of  dan- 
ger to  the  lives,  health  or  safety  of  persons  employed  therein 
as  to  require  special  reg-ulation  for  the  protection  of  such 
persons,  the  commission  shall  have  power  to  make  special 
rules  and  regulations  to  guard  against  such  elements  of  dan- 
ger by  establishing  requirement  as  to  temperature,  humidity, 
the  removal  of  dusts,  gases  or  fumes  and  requiring  licenses 
to  be  applied  for  and  issued  by  the  commission  as  a  condi- 
tion of  cari-ying  on  any  such  industry,  trade,  occupation  or 
process  and  requiring  medical  inspection  and  supervision  of 
persons  employed  and  applying  for  employment,  an<:l  by 
other  appropriate  means. 

(4)  The  i-ules  and  regulations  may  be  limited  in  their 
application  to  certain  classes  of  establishments,  places  of 
employment,  machines,  apparatus,  articles,  processes,  indus- 
tries, trades  or  occupations  or  may  apply  only  to  those  to  be 
constructed,  established,  installed  or  provided  in  the  future. 


236  State  Department  of  Health 

(5)  The  rules  and  regiilatious  of  the  comiiiissiou  shall 
have  the  force  and  eii'ect  of  law  and  shikU  be  enforc-ed  in  the 
same  manner  as  the  provisions  of  this  chapt-er. 

{(y)  Ko  provision  oi  this  chapter  specifically  conferring 
power  on  the  commission  to  make  rules  and  regulations  shall 
limit  the  power  confeiTed  by  this  section. 

§  53.  Bureau  of  inspection;  hispector  general;  divisions. 
The  bureau  of  inspection,  subject  to  the  supervision  and 
direction  of  the  commissioner  of  labor,  shall  have  charge- 
of  all  inspections  made  pursuant  to  the  provisions  of  this 
chapter,  and  shall  perfoi-m  such  other  duties  as  may  be 
assigned  to  it  by  the  commissioner  of  labor.  The  first  deputy 
commissioner  of  labor  shall  be  the  inspector  g-eneral  of  the 
state,  and  in  charge  of  this  bureau  subject  to  the  direction 
and  supervision  of  the  commissioner  of  labor,  except  that  the 
division  of  industrial  hygiene  shall  be  under  the  immediate 
direction  and  supervision  of  the  commissioner  of  labor. 
Such  bureau  shall  have  four  divisions  as  follows:  factory 
inspection,  homework  inspection,  mercantile  inspection  and 
industrial  hygiene.  There  shall  be  such  other  divisions  in 
such  bureau  as  the  commissioner  of  labor  may  deem  neces- 
sary. In  addition  to  their  respective  duties  as  prescribed  by 
the  provisions  of  this  chapter,  such  divisions  shall  perform 
such  other  duties  as  may  be  as&igTicd  to  them  Iw  the  com- 
missioner of  la])or. 

§  54.  Inspectors. —  1.  Factory  inspectors.  There  may  be 
appointed  not  more  than  two  hundred  and  twenty-five  fac- 
tory ins]>ectojs,  not  more  than  fifty  of  whom  shall  he  women, 
within  the  appropriation  granted  by  the  legislature.  Such 
inspectors  shall  be  appointed  by  the  commission  and  may  be 
removed  by  it  at  any  time.  The  inspectors  shall  l^e  divided 
into  seven  gi*ades. 

*  ■?:-  *  •;<-  *  * 

Of  the  inspectors  of  the  seventh  grade  one  shall  be  a 
physician  duly  licensed  to  practice  medicine  in  the  state  of 
I^ew  York,  and  he  shall  be  the  chief  medical  inspector :  one 
shall  be  a  chemical  engineer ;  one  shaJl  be  a  mechanical  engi- 
neer, and  an  expert  in  ventilation  and  accident  lu-eveution; 
and  one  shall  be  a  civil  engineer,  and  one  an  expert  in  fire 
preventioru 

§  GO,  Divbiion  of  industrial  hi/giene. —  The  ins]>ectors  of 
the  seventh  gra'de  shall  constitute  the  division  of  industrial 
hygiene,  which  shall  be  under  the  immediate  charge  of  the 
commissioner  of  labor.   The  commissioner  of  labor  mav  select 


Public  Health  Nuesing  237 

ouo  of  the  inspectors  of  the  seventh  grade  to  act  as  the 
dii'ector  of  such,  division.  *  *  *  Xhe  members  of  the 
division  of  industrial  hygiene  shall  make  special  inspections 
of  factories,  mercantile  establishments  and  other  places  sub- 
ject to  the  provisions  of  this  chapter,  throughout  the  state,  and 
shall  conduct  special  investigations  of  industrial  processes  and 
conditions.  The  commissioner  of  labor  shall  submit  to  the 
industrial  board  the  recommendations  of  the  division  regard- 
ing i>roposed  rules  and  reg-ulations  and  standai'ds  to  be 
adopted  to  carry  into  effect  the  provisions  of  this  chapter  and 
shall  advise  said  board  concerning  the  operation  of  such 
i-ules  and  standards  and  as  to  any  changes  or  modifications 
to  be  made  therein.  The  members  of  such  division  shall 
prepare  material  for  leaflets  and  bulletins  calling  attention  to 
dangers  in  particular  industries  and  the  precautions  to  be 
taken  to  avoid  them;  and  shall  perform  such  otkefr  duties 
and  render  such  other  services  as  may  be  required  by  the 
commissioner  of  labor.  The  director  of  such  division  shall 
make  an  annual  i-^port  to  the  commissioner  of  labor  of  the 
operation  of  the  division,  to  which  may  Ije  attached  the 
individual  reports  of  each  member  of  the  division  as  above 
specified,  and  same  shall  be  transmitted  to  th-e  legislature 
as  part  of  the  annual  report  of  the  comiuissioner  of  labor. 

§  61.  Section  of  medical  inspection. —  The  inspectors  of  the 
sixth  grade  shall  constitute  the  section  of  medical  inspection 
which  shall,  subject  to  the  supervision  and  direction  of  the 
director  of  the  division  of  industrial  hygiene,  Ise  under  the 
immediate  charge  of  the  chief  medical  inspector.  The  sec- 
tion of  medical  inspection  shall  inspect  factories,  mercantile 
estalilishments  and  other  places  subject  to  the  provisions  of 
this'  chapter  throughout  the  state  with  respect  to  conditions  of 
work  aifecting  the  health  of  persons  employed  therein  and 
shall  have  charge  of  the  physical  examination  and  medical 
supervision  of  all  children  employed  therein  and  shall  per- 
fonn  such  other  duties  and  render  such  other  services  as  the 
commissioner  of  labor  mav  direct. 


Industrial  hygiciie  constitutes  in  itself  a  separate  branch  of  sani- 
tary science,  in  which  various  medical,  economic,  and  sociologic 
aspects  are  closely  interwoven,  and  which  can  not  be  handled  in  a 
cursory  manner  or  without  intimate  knowledge  of  the  conditions 
involved.  jMoreover,  the  problems  of  each  community  -present  in- 
dividual characteristics  depending  upon  local  conditions,  which 


238  State  Departimient  of  Health 

should  be  the  subject  of  special  study,  iu  order  to  determine  their 
effects  on  the  public  health.  One  of  the  results  of  the  creation  of 
general  industrial,  part-time  and  unit-trades  schools  to  be  admin- 
istered by  the  State  Department  of  Education,  schools  which  will 
participate  in  State  and  Federal  aid,  compulsory  physical  educa- 
tion and  compulsory  medical  inspection,  will  be  the  extension  of 
good  health  education  and  supervision  to  working  minors  and  to 
adults  required  to  attend  instruction  in  these  schools.  Medical  in- 
spection of  factories-  and  mercantile  establishments  and  health 
supervision  of  children  employed  therein  are  administered  under 
the  Labor  Law,      (See  section  61  of  Labor  Law.) 

The  public  health  nurse  will  therefore  be  more  concerned  with 
those  factors  which  pertain  to  personal  or  private  hygiene, 
and  which  can  be  best  dealt  with  by  populair  education  in  the 
home,  than  with  those  of  a  public  nature  which  can  be  controlled 
only  by  definite  pubjlic;  a,uthorities.  iBut  sine©  she  may  be 
required  to  assist  in  the  prevention  and  supeiwision  of  the  diseases 
of  occupation,  she  should  have  a  general  knowledge  of  the  prob- 
lems involved. 

Peoblems 

The  problems  involved  in  industrial  hygiene  relate  to  hours 
of  labor,  to  fatigue  under  various  conditions,  to  the  labor  of 
women  (and  of  children)  as  it  affects  both  them  and  their 
offspring.  In  workshops,  as  in  dwellings  they  deal  with  tlie 
subject  of  ventilation,  of  detrimental  substances  in  the 
air,  such  as  dust,  fumes,  gases,  etc.,  of  cleanliness  and  decency, 
and  of  communication  of  diseases,  as  by  spitting  and  the  like. 
In  addition  there  is  a  large  class  of  problems  of  a  more  special 
nature  relating  to  diseases  of  occupation  which  are  to  be  prevented 
or  controlled,  each  different  industry  exerting  its  own  particular 
effect  on  health.  Besides  the  actual  sanitaiy  conditions,  there 
are  also  questions  of  safety  and  of  social  welfare  of  the  workers, 
which  are  also  related  to  those  of  health.  Every  community,  how- 
ever small,  has  its  industrial  problems  which  can  not  be  neglected 
for  even  whea-e  there  are  no  factories,  properly  speaking,  there 
are  always  such  establishments  as  bakeries  and  other  places 
where  food  is  prepared,  laundries,  stores,  etc.,  in  which  the  health 
of   the   workers   is    an    important    consideration.      Bakeries    and 


Public  Health  Nuesing  239 

laundries  also  come  under  the  supervision  of  the  State  Industrial 
Commiasion.     (See  Pars.  117  and  92  of  Labor  Law). 

The  enforcement  of  the  Labor  Law  relative  to  the  ouiployiiient 
of  women  and  children  in  mercantile  estahlishments  in  all  cities 
is  under  the  jurisdiction  of  the  Industrial  Commission.  Enforce- 
ment in  villages  of  8,000  or  more  population  is  under  local  boards 
of  health. 

Occupational  Diseases 

Occupational  diseases  have  been  classified  by  Oliver  as 
follows:  (1)  those  due  to  gases,  vapors  and  high  temperature; 
(2)  those  due  to  conditions  of  atmospheric  pressure;  (3)  thoso 
due  to  metallic  poisons,  dusts  and  fumes ;  (4)  those  due  to 
organic  or  inorganic  dust  and  heated  atmosphere;  and  (5) 
those  due  to  fatigue.  This  is,  of  course,  an  arbitrary  classification, 
to  which  may  be  added  those  diseases  due  to  lighting  condition 
in  relation  to  eye  strain,  aaid  those  due  to  noise  in  relation  to 
nervous  disorders. 

Among  the  more  common  diseases  of  occupation  may  be  men- 
tioned :  Poisoning  by  lead,  phosphorus,  arsenic,  mercury,  and 
brass;  caisson  disease;  and  parasitic  diseases  such  as  anthrax 
(wool  sorter's  disease)  and  hook  worm  disease  (miner's  anemia). 
The  relation  of  dusty  trades  and  other  depressing  industrial  con- 
ditions to  tuberculosis  is  a  very  important  aspect  of  the  problem 
and  one  in  which  the  public  health  nurse  should  be  particularly 
intei'estcd,  for  tuberculosis  is  frequently  found  among  workers 
in  dusty  trades.  The  problem  of  tuberculosis  is  so  closely 
bound  up  with  personal  habits  and  home  life,  that  it  is 
quite  as  proper  to  consider  it  a  house  disease  as  an  occupa- 
tional disease.  Statistics  show,  ho\vevei\  lli.it  tuberculosis  is 
unusually  prevalent  among  grinders,  engravers,  compositors, 
stone  workers,  millers,  bakers,  plasterers,  brass  workers,  glass 
cutters,  furriers,  weavers,  and  persons  in  other  trades  in  which 
there  is  undue  exposure  to  dust  and  irritating  vapors. 

Much  of  the  dust  raised  in  industrial  processes  may  be  limited 
by  improvements  in  machinery  and  preventive  devices  such  as' 
the  wet  processes.  Certain  dusty  operations  may  be  conducted 
in  inclosed  hoods  or  special  cal)inets  so  as  to  confine  the  dust  and 
thus  protect  the  workers,  or  the  dust  may  be  removed  by  sue- 


240  State  DErARTjsraisrT  of  Health 

tion  fAii  devices.  Good  ventilation  greatly  diminishes  the  danger. 
When  workin^'n  are  compelled  to  stay  in  diisty  atmospheres  they 
should  wear  respiratory  masks.  The  dangerous  eifects  of  irritat- 
ing or  poisonous  gases  may  he  prevented  by  wearing  special  gas 
masjiks.  The  trouble  is  to  make  the  workmen  wear  these  masks ; 
they  prefer  taking  chances  to  wearing  uncomfortable  respirators. 
—  until,  perhaps,  it  is  too  late. 

In  j^ew^  Yo.rk  State  physicians  are  required  to  report  to  the 
State  Industrial  Commission  all  cases  of  industrial  poisoning  or 
disease  which  come  to  their  attention.  (See  Article  5,  Section  65 
of  the  Labor  Law.) 

Public  health  nurses  should  make  themselves  familiar  with 
terms  and  conditions  applying  to  industry  as  specified  in  the 
Labor  Law.  Copies  of  this  law  and  of  the  rules  and  regulations 
established  by  the  State  Industrial  Commission  may  be  had  on 
application  to  the  Commission. 


INDEX 


PAGE 

Abatement  of  insanitary  conditions 23 

nuisances     32-33 

Abortions    J[JO 

Adenoids,  effect  of ^•^' 

Adolescent  children,  minimum  standards  for 184 

Adulteration   of   milk 42 

detected  by  specific  gravity  test 44 

Advertising  health ^^^ 

After-care  of  discharged  tuberculosis  sanatorium  patients US 

of    infantile    paralysis ^211 

Agents  in  transmission  of  disease 23-24 

American  Red  Cross,  field  of 3^ 

Analysis  of  water,  chemical 58 

sanitary    58 

Antitoxin,   diphtheria    140 

outdated  packages    140 

treatment   142 

tetanus    _• ^^^'^^J 

Aseptic  precautions  in  cases  of  communicable  diseases .•  ■  •  •  ^ 

Authority  for  employing  public  health  nurses  by  state  commissioner 

of  health    5 

by  health   officers    <| 

by  boards   of   trustees G 

by  boards  of  education 6 

by  county   tuberculosis   hospital 6 

and  legal  status  of  public  health  nurse 10-11 

of  local  boards  of  health  to  make  regulations 95 

Bacillary  dysentery   14j^ 

Bacteria  in  milk    


40 


water 


53 


Bacterial  count  of  milk 41-42,  46 

Bacteriological   examination   of   water 61 

reports   of   water    examinations '52 

Barnyard  conditions    -■^ 

Bed  bugs,  extermination  of ^2 

Birth  certificates    166 

Births,  reporting  by  midwives 187 

imreported    1^^ 

Blind  child,  education  of 207 

Blindness   and   sore   eyes 197 

reporting     19^ 

prevention  and  relief  of 198 

Blood  examinations  for  typhoid  fever 14-^ 

paratyphoid  fever    146 

dysentery     _   1 4*") 

malaria  organisms    •  •  147-14S' 

Board  of  education,  England's   recommendations  for   instruction   in 

infant   care    "^"Jo^o? 

Breeding  places  for  insects o 

Burnham,  William,  characteristics  of  sane  mind 219 

Campaign,  publicity   Y^ 

for   cleanliness    "^^  '^" 

organizing   a  tuberculosis 128 

[241] 


242 


IXDEX 


PAGE 

Carriers  of  diseases,  diphtheria 144 

dysentery     146 

investigation     50 

Cerebros2>inal   meningitis   14S 

Cesspools    73 

Channels   and  modes   of  infection,   investigation   of 1!) 

Characteristics   of    sane   mind    2 If) 

Charities  law  governing  care  of  feeble-minded  children  by  State....  222 

commitments   to   asylums    222 

hearings  to  determine  mental  status  of  fee- 
ble-minded   children     222 

Chart,  boys   heiglit   and    weight 1S2 

girls  height  and   weight 181 

Charts     155-157 

Charts  and  maps,  use  of.   in   mailing   investigations 20 

Child,  mother's  care  of   5 

Children,    adolescent    184 

care   of  tuberculous    118 

correction  of  defects  in 1S>5 

physical  defects  in    193 

minimum  standards   for    183 

Children's  health  centers    176 

Child  welfare  activities  of  public  health  nurse 173-180 

for  infants  and  prescliool  children 176-177 

minimum  standards  for    174-177 

Child  welfare  nurse   17S 

duties   of    178-179 

instruction  of  girls  in  infant  care  and  management  by.  179-180 

knowledge  of   food   values 180 

relief  for  needy  cases 179 

weighing  and  measuring  children 180 

Child   welfare   station,   functions   of 17S 

Classification  of  cases  of  tuberculosis 1"7 

Classification  of  water  supplies 5.S 

Cleansing   and  disinfection    99 

Closing  schools  during  communicable  disease  outbreaks 137* 

Colon  bacilli   in   water 63 

Commissioner   of   Education    may    adopt    rules   in   regard   to    school 

medical  inspection    134 

Commitments  to  asylums   222 

Communicable  diseases,  diphtheria 141 

dysentery 146 

epidemic  cerebrospinal  meningitis 148 

gonorrhea 14:> 

malaria   147 

paratyphoid   fever    14fi 

pertussis    (whooping  cough)    147 

pneumonia 14S 

syphilis l-i*^ 

tetanus 14i! 

tuberculosis 144 

typhoid    fever    14(1 

Vincent's    angina    141 

Communicable    disease    among    school    children,    cooperation    in    the 

control  of   131 

complicating  tuberculosis   121-122 

control  of  19-21.  94 

knowledge  of  svmptoms  bv  school  teachers.  .  134 

list  of  reportable ." 95-96 


Index  243 

Communicable   disease  —  Continued  I'^QE 

on  dairy  farms   98 

outbreaks  of    131-134 

persons  coming  in  contact  with  cases  of,  for- 
bidden to  handle  food  for  pviblic  sale....  30' 

prevention   of    "4 

reporting 9.'j 

rules  and  regulations  for  health  officers  and 

school  medical  inspectors 135-137 

social  agencies,  assistance  from 103-104 

spread   by   milk    45 

Communicable  diseases  in  schools,  duties  of  health  officer 136-137 

duty   of   health   officer    to    investigate   unat- 
tended  cases    135 

duties  of  medical  school   inspector 136-137 

medical  officer  shall  notify  health  officer...    136-137 
Communicable  disease  outbreaks,  question  of  closing  schools  during.  13/ 

Community  actwn  on  public  health  problems 150 

Comparisons  of  vital  statistics  rates 162 

Compilation  of   tuberculosis   laws 117 

Complement  fixation  test  for  syphilis 148 

Conditions  affecting   vital   statistics 170-171 

inimical  to  health,   study  of 20 

to  be  observed  in  sanitary  survey 24 

Conduct  of   isolation   period 99 

Conferences,  attendance  at   1' 

Contact  bed   for   sewage   purification 84 

Control  of   communicable   disea.ses 19,  21,  94,  99 

cooperation  of  health  and  educational  author- 
ities   in     1*^0 

fly  breeding    27,  87 

house   drainage    28 

malaria 89 

rats     ;  ■       90-91 

Cooperation  in  control  of  communicable  diseases  among  school  chil- 
dren    131 

physical  education  and  health  supervision 218 

school  medical  inspection    130 

Cooperation   and  division   of   duties   among  workers   in  tuberculosis 

family     124-126 

of  health  and  educational  authorities  in  the  control  of 

communicable  diseases    130 

developed  through  working  for  common   cause .  iv 

in  control  of  communicable  disease  among  school  chil- 
dren   99 

publication  of  reports  necessary  to  secure   public v 

of  Red  Cross  with  local  groups iv 

of  school  and  health  authorities 20 

of  school  nurse  with  board  of  health 12 

with  other  philanthropic  agencies 20 

with  specializing  nurses 103 

with  various  charitable  organizations 20 

Corrected  death  rates 164 

Correction  of  eye  and  ear  defects 206-207 

malnutrition    211 

physical  defects  in  children 195 

County  law    f 

tuberculosis   nurse    10,  12,  14,  112 

Courses  of   instruction 1 ' 

Cultures   for   diagnosis 1*1 

release    142 


244  IxDEX 

PAOB 

Dairy   farms,   epidcjnics  on 3S 

reporting  communicable  diseases  on <JS 

rides  governing  yearly   inspections ,3S 

Danger  from  liuman  excretions .  .  .  /. 22' 

Data  for  laboratory  specimens 141 

Deaf  mutes,   care   of 207 

Death  certificates    166" 

rates    161 

Deaths,  from  tuberculosis 106 

nonresident     167.  168 

Decayed  teeth,  effect  on  health 196 

Decaying  substances,  as   nuisances    34 

classified     33 

eff"ect   on   health 24 

Defects,  correction  of   195 

of  the  feet   208, 210 

physical,  in  children 193 

results  of,  to  health 196 

Dental  service  in  cases  of  tuberculosis 120 

Detection  of  impurities  in  water 5b 

Diagnostic  tests,  examinations  by  state  laboratory 139 

required  by  sanitary  code '. 98 

Diphtheria  antitoxin     142,  143 

carriers    144 

cultures     141,  142 

immunity    143 

outfits    r 140 

quarantine    141 

Schick  test    143.  144 

smears    142 

toxin-antitoxin  treatment   143 

Directions  for  inspection  of  midwives 1S7 

Dirty  milk,  the  dirt  test 4:? 

Discovery  of  cases  of  tuberculosis 113 

of  unrecognized  and  unreported  cases  of  communicable  dis- 
eases      19 

Disease    carriers 23 

germs   in   milk    41 

Diseases   spread   by  milk 44.  45 

Disposal  of  garbage     26 

houseliold  drainage    26 

human  excrement   26 

sewage     66 

in  relation  to  water  supply 5.5 

of  institutions   and   municipalities S1-S6 

of  the   individual   home (16 

Disposition  of  tuberculosis  patients 116 

Division  of  duties  among  workers  in  tuberculous  family ]'l').  l'2i! 

Divisions   of   vital   statistics liin 

Drainage,   houseliold    26 

Dry  metliod  of  sewage  disposal (37 

Duties  of  pul)lic  health  nurse S 

in  ])ropaiing  newspaper  health  stories D")] 

in  suspected  cases  of  communicable  disea.se 9!) 

county   tuberculosis   nurses 10,  1 12 

municipal   nurses    9 

school  nurses 1 0.  2 1 2 

slate  nurses    s' 

Dutv.  hours  of    IS' 

of  person   havinir  tuberculosis 110 


Index  245 

PAGE 

Dysentery  carriers   -"^^^ 

Early  diagnosis  in  tuberculosis lOS 

Education  law  relating  to  blind   children    •  •  207 

cooperation    witli     health     authorities     in 

physical  welfare  of  children 130 

exclusion  from  school l-->i 

health  supervision  and  education  of  school 

child    18 

medical  inspection  of  school  children 133 

public  health  nursing 6 

Education  of  blind  child 207 

physical    .^l^ 

Emerson,  Harrington,  definition  of  a  record  and  a  report iv-v 

Employment  of  public  health  nurses  by  boards  of  education G 

board  of  trustees G 

commissioner    of   health.  ...  5 

county  tuberculosis  hospitals  6 

health   oflicers    5 

Red   Cross  county  chapters.  iv 

Entrance  to  premises,  duty  if  refused 12 

Environment  not  source  of  infection 2:i 

Epidemic  cerebrospinal  meningitis    1"^^ 

Epidemics   among  school  children •  •  •  •    131-134: 

investigation   of    1^ 

Estimates  of  population 1*^1 

Examination  of  water,  bacteriological 61 

for  eye  and  ear  defects 19*> 

Examinations  by  state  laboratory 139, 1&8 

Exclusion  from  school  in  cases  of  communicable  diseases 131 

Exclusion  rules,  knowledge  of,  by  school  teachers 134 

Excrement,  disposal  of  human 26,  66 

Expenses,  record  of v 

Extermination   of   mosquitoes 27,  89 

Eve  defects    197" 

tests  for   19S 

Eye  and  ear  tests  of  school  children •         19S 

instruction    to    teachers 198 

Fatality  rate   164 

Fat  in  milk,  test  for 44 

Feeble-minded  children,  care  of,  by  state 222 

commitment  of    222 

hearings  to  determine  mental  status  of 222 

Feeble-mindedness,  societies  dealing  with 222 

diagnosis  of   223 

Field  work   15 

Filtration  of  sewage,  slow  sand 82 

water  sui>plies    64 

Flies,  methods  of  controlling  spread  of  disease  by 87-8^ 

Fly  control 27,  87 

breeding  classified  as  nuisance 33 

Food  handling   19 

by  persons  having  tuberculosis 110. 

forbidden  in  certain  cases 30 

inspection  of  methods  of 29 

Fumigation,  terminal    133 

Functions  of  public  health  laboratory 139 

Funds  for  tuberculosis  work 129 

securing   of,   for   health   activities iv 

Garbage  disposal    26 

piles    34 


246  Index 


PAGE 

Gonorrhea  and  sypliilis   100 

specimens    149 

Grading   milk    4S 

Graphs    '....'.'.'.  156,  157 

Habits  of  person  having  tuberculosis 110-111 

Hardness  in  water (j(j 

Hard  water   51 

Health  laws,  penalties  for  violation  of 18() 

literature    154 

preparing  copy    151 

officer,  duties  in  caises  of  communicable  diseases  in  schools.  131-136 

duties  regarding  laboratory   supplies 140 

duty  to  investigate  cases  of  unattended  communicable 

disease    136 

must  countersign   school  medical  certificates 134 

relation  of  public  health  nurse  to 14 

rules    and    regulations    for,    in    the   control    of    com- 
municable diseases  in  schools 135-137 

to  take  release  cultures 142 

Health  supervision,  cooperation   in 21S 

and  education  of  school  diild 21,  183,  192 

Hearing  tests    204 

Heating,  methods  of 230-233 

Height  and  weight  chart  for  boys 1S2 

girls    ISl 

Home,  instruction   in    5 

and  workshop,  hygiene  of 21 

Home  pasteurization   of  milk 47 

supervision  of  tuberculosis  patients US 

treatment   of   tuberculosis 117 

House  heating    230 

light,   lack   of    225 

lighting 233 

overcrowding    224 

plumbing  inspection   226 

types  of  dwellings 226 

uncleanliness    225 

ventilation    225,  227-230 

Housing  conditions     25,  224-227 

Household    drainage    26. 66 

filtration  of  water 65 

Human  excrement,  disposal  of 26.  66 

Hygiene,  industrial    234 

of  home  and  workshop 21 .  224-240 

Iceless    ice-box    49 

Ignorance  in  home,  menace  to  health 6 

niuminating  gas,  dangers  from 233' 

Immunity    to  diphtheria    143 

])aratyphoid   fever    146 

typhoid  fever   145 

Impurities   in   water 52-53 

prevention    of    63 

Industrial   commission     234 

inspection   of   factories    236 

diseases,  reporting  of    240 

rules   and    regulations   regarding 235 

liygiene    234 

labor  law    234 

medical  inspection    236 

poisoning,  reporting  of 240 


Index  -247 

PAGE 

Infant  care  and  feeding,  instruction  of  girls  in 170 

management,    recommendations    for 170-180 

Infants  and  preschool  children 176-177 

Infant  mortality  problem,  solution  of 178 

rate    165,  173-174 

welfare  activities    20 

Infection,  investigation  of.  modes  of 19 

food     33 

milk     : 33 

water     33, 50 

Information  regarding  communicable  disease 09 

Insanitary  conditions,  abatement  of   23 

effect   on  health 23 

importance  of    22 

prevention    of    21 

Insanitary  homes  and  tuberculous  cases 122-123 

Insects,  control  of 87* 

Inspection  of  bakeries     30-32 

breeding  places  for  flies,  etc 27 

confectioneries     32 

dairies   28,  38,  46 

disposal  of  human  excrement 26 

eating  houses    30 

garbage   disposal   methods 26 

household  drainage  methods 26 

housing    25 

markets     30-32 

methods  of   food  handling 29-30 

midwives,   directions   for    187 

milk  supplies 28,  31,  46 

mosquito  breeding  places 27 

places  where  food  is  sold 30-31 

premises  by  nurse    12 

premises  for  nuisances 3'^ 

public  buildings    227 

restaurants     30 

sanitary  conditions,  see  sanitary  inspection 

school  children  in  absence  of  school  nurse 94 

soda   fountains    30-32 

water  supplies  28-31 

Institutions,  disposal  of  sewage  of 80-86 

cases  of  tuberculosis  in IIT 

Instruction,    courses   of.   for   nurses 17 

in  conducting  isolation  period  in  home 38 

in  personal  hygiene  in  homes 5 

of  public  in  measures  to  prevent  spread  of  infection.  ...  10 

regarding  care   of   patient 94 

to  be  given  as  result  of  sanitary  inspection 31 

Instructions  for  cleansing  and  disinfection 90 

to  teachers  for  examination  of  eyes  and  ears ' 19i5 

Irterpretation    of  water   analyses 59 

Investigation  of  breeding  places  of  insects 19' 

epidemics 16 

regarding   food   sanitation lO 

modes  and  channels  of  infection 19' 

nuisances    11 


248  Index 

Investigation  of  —  Continued  page 

sanitary  conditions  on  dairy  farms 38 

sewage  and  waste  disposal H> 

water  supplies  19,  50 

Investigations,   for   discovery   of  unreported   cases   of   communicable 

disease     20 

Iron  in  water 52 

Irrigation  system  of  sewage  disposal 74-79 

Isolation  of  cases  of  tuberculosis 109 

Itch  mites,  extermination  of   9.3 

Jr.niijr  health  officers,  for  school  rooms 134 

reports     133 

Laboratory  examinations     139 

diphtheria     142 

dysentery    146 

Ijaratyjihoid   fever    14fi 

smears  froni  sore  eyes 19^ 

tuberculosis    144-145 

typhoid  fever 145 

Vincent's   angina    142 

Laboratory,  local     13<I 

•    public  health 138 

reports   of    139 

service     140 

State    139 

supplies     139,  140 

Laboratory  specimens,  examinations  for  tuberculosis 109,  11(3 

reports  on    59 

securing    20, 31 

tests   on,   required  by   sanitary   code 9S 

Labor  law,  governing  industrial  hazard 235 

diseases     24t) 

hygiene     234. 23S 

medical  inspection    236, 238 

rules  and  regulations    235 

knowledge  of.  by  pul)lic  health  nurses 24i» 

Law,  see  public  health  law 

Laws,  regulations  and  orders , 12 

Legal  status  of  public  health  niu-ses !(► 

right  to  inspect  premises 24 

Legislation,  see  public  health  laws 

Lice   91-92 

Local  public  health  laboratories 139 

Light,  lack  of  sufficient 225 

Lighting,  dangers  of  illuminating  gas 23'5 

advantage   of   electric 234 

Literature  for  free  distribution 154 

Local  supply  stations 140 

Malaria,  control    of    S7 

diagnosis    of    147 

dissemination  of   147 

Malnutrition  of  child 210-211 

Manual  on  comnuinicable  diseases 99 

Maps  and  charts  in  nu^king  investigations 20 

Marriage,  eH'ect  of  on  movement  of  population 162 

rates    165 

Maternity  cases  in  family  of  tuberculous  patient 122 

centers     175-176 

Measures  for  prevention  and  control  of  tuberculosis 108 


Index  249 

PAGE 

Medical  emergencies  in  tuberculosis 120-121 

inspection  law  governing  eye  and  ear  tests 108 

school  inspectors  must  examine  pupils  on  return  to  school 

without  medical  certificate    134 

school  insi>ectors  must  countersign  school  certificate 134 

school  inspectors,  rules  and  regulations  for 135-137 

Meningitis,  cerebrospinal    14S 

Mental  defectives    221 

Mental  hygiene    21,  219-223 

clinics    220 

defects,  prevention  of 21 

Methods  of  advertising  healtli    150 

garbage   disposal    26 

securing  correction  of  defects  in  children ID.) 

securing   space   in   newspapers 152,  153 

water  filtration   6-* 

Midwives,  birth  certificates  to  be  filed  by 186 

equipment  of   188 

inspection  of   187-190 

licenses    185 

must  keep  and  use  ophthalmia  neontariun  outfits 186 

must   record   births 187 

must  report  stillbirths 186 

penalties  for  failure  to  report  births 186 

violation  of  regulations  governing  practice  of  186 

regulation  governing  practice  of 185 

reports  on  inspection  of 189 

supervision  of    20,  185 

unlicensed     191 

what,  must  do  to  practice 185 

Midwifery,  sanitary  code  in  relation  to  practice  of 185 

penal  code  in  relation  to  practice  of 185 

Milk  and  eggs  for  tuberculous  patients 12S 

Milk,    adulteration  of   42 

animal   diseases  contracted  through 44 

bacteria  in   40 

bacterial  count  of   41-42.  46 

borne  epidemics 31,  38-39 

collection  of  samples  of 42 

composition   of    43 

conditions  governing  production  of  pure 39 

cooling  of   4/ 

curdling    of    40 

dirty,  the  dirt  test 42 

disease  germs  in   41 

diseases  spread  by   44-45 

grading     47 

pasteurization  of    46 

permits  for  sale  of 38,4.^ 

procedures  with  suspected  milk 48 

quality    of    39 

scoring   of 4^6 

slimy  or  ropy  milk 41 

souring  of 40 

specific  gravity  test  for  adulteration  of 44 

supply,  infection  of 3.*? 

inspection    28.  38 

tastes  and  odors  in 41 


250  Index 

Milk  —  Coniimted  page 

test  for  fat  in   44 

thin  and  watery 41 

total   solids    in 44 

wholesome    44 

Minimum  standai-ds  for  child  welfare 174,  177,  IS:^ 

for  adolescent  children   1S4 

Miscarriages    160 

Modes  and  channels  of  infection,  investigation  of 11) 

Monthly  reports,  publishing 153 

Morbidity  statistics   164 

Mosquito  breeding,  classified  as  nuisance 33 

extermination     27, 89 

larvae   and   pupae,  collection   of S9 

Mother  and  child,  home  instruction  of,  in  personal  hygiene 5 

Movement   of   population 162 

Municipalities,  disposal  of  sewage  of SO-SG 

Natural  growth  of  commimity 161 

Necessity  for  birth  and  death  registration 166 

Newspaper   health   publicity 150-151 

Newspapers,  methods  of  securing  space  in 151-152 

monthly  reports  should  be  published  in 153 

rules  to  be  observed  in  preparing  copy  for 151-152 

Nonresident  deaths    167 

Nuisances,  abatement    of .  32-33 

authorization  of  nurse  to  inspect 11 

board  of  health's  power  to  deal  with 11 

classification   of    33 

directly    affecting    health 33 

indirectly  afl"ecting  health 34 

other   torms   of 3o 

private  drains   35 

Nurse,  see  public  health  nurse 

and  communicable  disease 04 

Objects  of  sewage  purification 81-82 

Obnoxious   fumes    34 

Occupational  conditions  detrimental  to  health 238 

diseases    239 

Odors  from   privies    34 

in  milk    41 

in  water   (>i'i 

Ollice   work   of   public    heallh    luirse 16 

Official  standing  of  public  health  nurse  if  Ijoard  of  health  appoints  as 

agent   of   health   ollicer 12 

Open  air  scliools 193 

Opposition  to  investigation,  tiibci'culosis  nurse  nuist  report  to  proper 

authority    12 

Ophthalmia  neononatorum   outfits 182 

Organizing  a  local  tuberc\dosis  campaign 128 

Orthopedic  defects  of  childien 208-210 

nurse,   services   of   state 212 

surgeon,  services  of  state 212 

Outbreaks   of   communicable   diseases 131-134 

Outdated   laboratory   supplies 146 

Overcrowding   of   dwellings 225 

Paralysis,    postdiphtheritic    143 

Paratyphoid   fever    146 

Part-time  schools,  physical  cducal  on   in 216-217 

Pasteurization  of  milk 4()-47 

Pediculosis     91, 92 


Index  251 

PAGE 

Penal  code  in  lelatiun  to  practice  of  midwifery 185 

sore  eyes   197 

Penalties,  for  violation  of  regulations  of  sanitary  code 186 

health  laws    '. 186 

failure  to  report  births 186 

Permit  for  sale  of  milk  necessary 38,  48 

Personal   educational   work 151,  158,  159 

Pertussis     147 

vaccine    147 

Physical  defects  in  the  child 193 

Physical  education  in  schools 213 

coojjeration  in   218 

general  plan  of 215-216 

part-time  schools   216-217 

Physician,  relation  of  public  health  nurse  to 14 

required  to  report   conmiunicable   diseases 95 

Plumbing  inspection    226 

Pneumonia     148 

serum    14S 

specimens     14& 

Poliomyelitis,  after-care    211 

Pollution  of  water  supplies 50-54 

source   of    53 

Population  in  relation  to  vital  statistics 160 

Postdiphtheritic    paralysis     143 

Practice  of  midwifery   185 

conditions  of   185-186 

penalties  for  violations  of  regulations  govern- 
ing       186 

Predisposing  causes  of  mental  disorder 220 

Pregnant  mothers,  advice  to 103 

Prenatal  care     ^     179 

centers     175-176 

Press,  furnishing  material  for 20 

warnings   in   epidemics 133 

Principles  governing  tlie  securing  of  pure  water  supply 50 

Prevention  of  communicable  diseases    94,  99 

impurities  in  water  supply 6.> 

tuberculosis    10b 

Preventorium  for  tuberculosis  cases 118 

Privies,  removable  receptacle  for ^^~^i 

types   of    67 

underground  vault    (dug) ^^~^^ 

watertight  vault   72 

Procedures  to  be  taken  by  tuberculosis  patients 109-110 

and  precautions  with  suspected  milk 48 

Protection  of  public  health  nurse  for  acts  done  in  performances  of 

dutv     12 

Publications  for  public  health  nurses 99,  100,  106 

Publication  of  reports  in  newspapers v 

Public  buildings    227 

Public  cooperation  and  support,  necessary  for  nurses v 

Public  Health  Council,  qualifications  established  by,  for  state  super- 
vising public  health  nurses 7 

Public  health  education     20 

by  charts    155 

graphs   156 

literature    154 


252  Index 

Public  health  education  —  Continued  page 

by  personal    contact    158 

spot  maps    156 

the  newspaper   151 

methods  employed  in    150 

the  nurse  in    150 

Public  health  laboratory     13S 

functions  of  139 

local     139 

state    139 

Public  health  laws,  employment  of  public  health  nurses  by  board  of 

trustees  of  schools ! 6 

county  tuberculosis  iiospital fi 

health  officer    5 

state  commissioner  of  health 5 

conflict   of   authority  regarding  physical  welfare 

of  scliool  children    ". 130 

enforcement  of    14 

penalty  for  violation  of 186 

published  in  public  health  manual 13 

Public  health  manual 99 

part  of  necessary  equipment 13 

Public  healtli  nurse     i 

abate!)ient  of  insanitary  conditions  by 23 

nuisances  by    32-34 

acting  for  school  nurse .  ." 94 

action  if  refused  admission  to  make  inspection..  24 

advice  by,  io  pregnant  mothers 103 

after-care   of    infantile   paralysis    by 211-212 

agent  of  health  officer \\l 

and  child  welfare  activities 173-180 

arousing   public    sentiment   through 20 

assignments    '. 5,  6,  15 

attendance   at   conferences 17 

breeding  places  of  insects,  investigation  by 19 

care  of  pregnant  women 179 

collecting  specimens  of  sputum 144 

control  of  comnnmieable  diseases 19-21 

cooperation  witli  school  and  health  authorities..  20 

other    philanthropic   agencies .  .  20 

specializing   nurses    10.5 

various  charitable  associations.  20 

correcting   malnutrition    210-211 

county 112 

procedure  if  denied  entrance  to  premises 12 

diplomacy  needed  by   94 

division  of  duties  with  other  tuberciilosis  work- 
ers      124-126 

duties  in  suppression  of  gonorrhea  and  syphilis.  .    101-102 

mental  hvgiene  cases   220 

duties   of    ' S-94 

in   cases   of   sore  eyes 197,  198 

duty  in  case  of  unlicensed   midwives 191 

unreported    deaths    190 

to  report  cases  of  food  poisoning M2 

effective  aid  to  health  officer 94 

employment  of,  by  boards  of  trustees  of  schools.  .  6,  12 

county  tuberculosis  hospitals.  (>.  12 

health  officer   5 

Red  Cross   iv 

state  commissioner  of  health.  5 


Index  2oe* 

Public  health  nurse  —  Continued  PAGE 

expenses 1^ 

familiarity  with  laboratory  procedures 13!) 

field   work    lf> 

food   sanitation,   investigation   by 1!' 

furnishing  material  for  press 20 

general  measures  used  by 20 

hours  of  duty   1^ 

housing  problems    25 

hygiene  of  home  and  workshop 21 

infant  care   and  management 179-lSO 

welfare   activities    20 

must  be  informed  on  conditions  governing  pure 

milk  supply   -^^ 

inspection   of   barnyard   conditions 27 

breeding  places  for  flies 27 

disposal  of  human  excrement   ....  26 

eating  houses   . 30 

general    topography    24 

methods  of  garbage  disposal   ....  26 

handling   food    29 

household   drainage  .  .  26 

midwives 1S7-190 

milk  supply    28,  3S 

mosquito  breeding  places    27 

places  where  food  is  sold 30 

public    buildings    227 

milk   supply    31 

water   supply 28,   31,   50,   53 

instruction  by,   in  methods   of   conducting  isola- 
tion  period 38 

instruction  of  girls  in  infant  care  and  feeding..  179 

instruction  by,  as  result  of  sanitary  inspection.  .  31 

interpretation   of   laboratory   reports 139 

investigation  for  discovery  of  unreported  cases.  .  20 

of  milkborne  epidemics 38-39 

of  nuisances    H 

knowledge  of  food  values ISO 

industrial   hygiene   problems    238-239 

labor   laws    240 

medical    emergencies    in    cases    of 
communicable       diseases       other 

than    tuberculosis    120-122 

symptoms  of  gonorrhea  and  syphi- 

lis 102 

law  jirotects  against  acts  done  in  performance  of 

duty 12 

legal  right  to  inspect  premises 24 

status   and   authority   of 10 

lines  of  work    IS 

mental  hygiene,  knowledge  of ,  by 21 

must  not  treat   sore   eyes 19^ 

necessary  knowledge  of  vital  statistics  by 160 

need  of   compilation   of   information  for iii 

office  work  of    ^" 

official  standing  of,  when  appointed  by  board  of 

health 1^ 

persoual   educational   work    of 158,^159 

powers    of    -. o,  iz 


254  I.^DEX 

Public  health  nurse  —  Continued  page 

preparation   of  maps   and    charts 20 

preparation  of  laboratory  specimens  for  mailing  141 

news   stories    151 

procedure  in  cases   of   subnormal   children 223 

tuberculosis  work  106 

publications   for    09-100 

public  health  education  by 20 

publishing   monthly   reports    153 

qualifications    of    ". 7.  94 

reading   for    17 

reasons  for   employment  of iii 

relation  to   sanitary  supervisor IS 

relief  for  needy  cases  by 179 

reporting  conimunicable'^  disease   95 

inspection  of  midwives  189 

imsatisfactory    garbage    disposal    con- 
ditions    27 

reports  of  work  to  proper  authority v 

research  work    * 17 

sanitary   inspections   by 22 

sanitary  inspection  of  occupied  premises 24 

instruction   in   tuberculosis  cases 119 

supervision  of  tuberculosis  cases 119 

surveys   by    19 

securing  laboratory  specimens    20. 31 

prenatal  care   179 

treatment  in  mental  cases 219 

sewage  disposal,  investigation  by 19 

social  work   of 124 

social  welfare  work  102-105 

source  of  authority   12 

power     5,  12 

special    articles   by    153 

special  courses  of  instruction  for 17 

duties  for  health  officer 94 

study  of  community  conditions 20 

supervision  of  health  of  school  children 21 

midwives 20 

quarantine 20 

taking  cultures  for  diagnosis  or  release 142 

specimens    from   women    for    examination 

for   gonorrhea    102 

testing  for  eye  and  ear  defects 19S-207 

testing  personal  immunity  to  diphtheria 144 

under  direction   of  health  officer 14 

visiting  homes  of  venereal  disease  clinic  patients  103 

vital  statistics  records    20 

water  supply  investigation    19 

weighing  and  measuring  children ISO 

Wf)rking  lilirary  for   100 

Public  health  nursing  and  tiibcrculosis 106 

Public  Health  Nurses'   Bulletin 100 

Public  health  nursing  in  New  York   State 5 

Publicity   campaigns    iv 

methods  150-159 

Public  sentiment,  arousing 20 

Public  water  supplies    50 

Pure  milk  supply,  conditions  governing 39 

water    supply    50-51 


Index  255 

PAGE 

Furification  of  sewage    82-86 

water 63 

Qualifications  of  registered  nurse ., 7 

Qualities  of  a  good  record v 

Quality  of  milk    39 

Quarantine,  release  from  diphtheria   141 

supervision   of    20 

Rain   water    53 

Rats  as  a  factor  in  spreading  disease 87 

extermination  of  90-91 

Reasons  for  registering  births  and  deaths 166-167 

Receipts   for  expenses 18 

Records,  in  tuberculous  cases 129 

of  school  nurse 132 

Records  and  reports    iv 

definition   of    iv 

Records,  developing    own    system    of v 

field  notes  for 16 

of   epidemics    16 

of  expenses    v 

of  inspection  of  places  where  food  is  sold 30 

qualities  of  good    v 

system  of  National  Organization  for  Public  Health  Nursing.  v 

tuberculosis    113 

Recreation  as  a  means  of  controlling  gonorrhea  and  syphilis 104-105 

Red  Cross,  field  of iv 

Registered  nurse,  qualifications   of 7 

requirements   to  practice   as 7 

Registration   districts    166 

of  births  and  deaths,  necessity  for 166-167 

of   midwives    185 

Registrars,  duties  of  local 166 

Regulations  for  health  officers  and  school  medical  inspectors 135 

Regulations  governing  practice  of  midwifery 185,  190 

release  from  diphtheria  quarantine 141 

specimens  for  diagnosis  of  typhoid  fever....  145 

taking  of  diphtheria  cultures 141 

issued  by  local  boards  of  health 13 

issued  by  state  commissioner  of  health 13 

Relation  of  public  health  nurse  to  health  officer 14 

physicians     14 

relief  organizations    15 

supervisor     18 

the  public    15 

Release  from  diphtheria  quarantine,  regulations 141 

Relief   in  tuberculosis   cases 123-124 

Reports  of  bacteriological  tests  of  water 62 

interpreting    laboratory    139 

monthly,  by  nurses 153 

of  water  analyses,  by  laboratory 59 

of  Junior  health  officers 135 

of  suspected  cases  of  tuberculosis 109,  115 

inspection    of    midwives 189 

Reporting   communicable   diseases 95 

on    dairy   farms 98 

industrial  diseases    240 

suspicious  cases  of  gonorrhea  and  syphilis 102 

Reports,  daily    17 

definition    iv,  6 

for   health   officer v 


256  IxDEx 

Reports  —  Continued  page 

nurse  must  keep  accurato 8 

of  oases  of  food  poisoning 32 

conditions  surrounding  water  supplies 50 

nuisances    3;! 

sanitary  conditions  of  buildings  and  premises 1!) 

tuberculosis  nurse  to  hospital   superintendent 12 

to  be  published  regularly v 

local  boards  of  health 10 

private  agencies   10 

Research  work    17 

Right  of  entrance  and  inspection  in  tuberculosis 127 

Ropy  milk    41 

Rules  to  be  observed  in  preparing  newspaper  articles 151-152 

Salesmanship  methods  for  health  education 217-21S 

Samples,  collection  of  milk  or  water 31,  42 

collection   of   water 58,  62 

Sanitary  analysis  of  water 58 

Sanitary  code  in   relation  to  exclusion   of  children  from   school....  131 

midwifery     185 

penalties  for  violation  of  regulations  of  186 

release  from  diphtheria  quarantine.  .  141 

typhoid  specimens    145 

publications  of  changes  in 10(> 

requires  certificate  for  return  to  school  after  illness.  133-134 
householders  to  report  communicable  diseases  133 
taking  cultures   in   cases  of  suspected  diph- 
theria      141 

Sanitary  insiJection    of  barnyard  conditions   27 

in  regard  to  cleanliness 25 

of  disix>sal  of  human  excrement 26 

fly  control    27 

food  handling    20 

garbage    disposal    26 

general  topography    24 

housing     25 

household  drainage    2(> 

milk  supply   ■ 2S 

mosquito  extermination    27 

occupied   promises    24 

water  supply   28 

Sanitary  instruction  in  tuberculosis 119-120 

supervision   in   tuberculosis 110 

supervisor,  relation  of  nurse  to IS 

Sanitation,  key  notes   of 10-22 

Sanitary  surveys    10 

important   points   in    22 

of  watershed    54 

water   supplies    5"i 

Sanatorium  treatment  for  cases  of  tid>orculosis 100.  Ill 

School,  communicable   diseases    in 135-137 

exclusion  from,  of  cases  of  communicable  disease 131 

children,  mininnim  stiindards  in  child  welfare  for 183 

tests  for  eye  and  oar  defects 108-200 

nurse,  cooperation   in  care  of  mental  defectives 221 

correcting   malnutrition    210-21  I 

duties  of,  in  outl)reaks  of  commiuiicable  di.sease 132 

functions  and   duties  of 5,  10.  12.  102 

nu'thods  of  securing  correction  of  dofocts  by 105 

preventing    foot    (U'fecls 208-210 

securing  interest  in  open  air  schools 103 


Index  257 

School  —  Continued  PAGE 
nurge  —  Continued 

suggested  duties  of    212 

testing  eye  and  ear  defects 198-207 

medical  inspection  and  school  certificates 134 

in  cases  of  communicable  disease 131-134 

cooperation  in   130 

rules   and  regulations   for 135-137 

trustees  authority  to  close  schools  during  communicable  dis- 
ease  outbreaks    137 

Schools,  desirability  of  not  closing,  during  disease  outbreaks 137 

physical  education  in   213-217 

Score  card  system  for  inspection  of  dairies 46 

Securing  a  nurse    "i 

laboratory    specimens    20 

specimens  for  examination  for  gonorrhea 102 

specimens  of  mosquito  larvae  and  pupae 90 

Septic  tank  method  of  sewage  disposal 83 

Serum,  pneumonia   148 

Sewage  and  waste  disposal 19 

Sewage    disposal,    cesspools 73-74 

for  institutions  and  municipalities 81-83 

system  in  relation  to  water  supply 55 

subsurface   irrigation   system 74r-79 

water  carriage  systems  of 72-73 

chemical  precipitation  of 82-83 

composition   of    80 

contact    beds    for 84 

disinfection    of    86 

methods  of  purification  of 82 

sanitary  methods  of  disposal  of 66 

septic  tank,  method  of  purifying 83-84 

slow  sand  filtration  of 82-84 

sprinkling  filters  for    85 

when  constituting  a  nuisance 5 

Schick   test    143,  144 

Slow   sand   filtration  of  sewage 82-84 

Specific    death   rates 163 

Smears  from  sore  eyes,  examination  of 198 

Smoke   nuisances    _ _ 35 

Social  agencies  cooperating  in  suppression  of  communicable  diseases.  103-105 

Social  welfare  work 102-105 

work  of  public  health  nurse 124 

Sources    of   pollution    of   water 54 

Souring  of  milk 40 

Sore    eyes     197 

Special"  orders,  public  health  nurse  subject  to 14 

Specific  gravity  of  milk 44 

Specimens,  blood    145 

gonorrhea     149 

malaria   diagnosis    147 

paratyphoid   diagnosis    146 

pneumonia    148 

securing  laboratory   20 

syphilis     148 

Spinal  puncture    148 

Spontaneous  pneumothorax    121 

Spot  maps    156 

Sprinkling  beds  for  sewage  purification 85 

Standard  methods  of  milk  examination 42 

population    165 

9 


268  Index 

PAGE 

standardized  death  rate  164 

Standards  for  child  welfare  work 174-177 

State  supervising  nurses,  duties  of 9 

public  health  laboratory,  examinations  made  by 139 

Statutory  requirements,  in  relation  to  nuisances 35 

Sterilization  of  water 63-64 

StiUbirths    160,  173 

Study  of  conditions  inimical  to  health 20 

Subnormal    children    223 

Subsurface  irrigation  system  of  sewage  disposal 74-79 

Supervising  public  health  nurses,  duties  of    8 

legal  authority  of 11 

procedure  if  opposed 11 

Supervision  in  control  of  communicable  diseases 19 

of  health  of  school  child 21, 183 

midwlves    20,  185 

■quarantine    20 

Supply  stations    140 

Surface  water   54 

Survey,  tuberculosis    112, 113 

Symptoms  of  communicable  disease,  knowledge  of,  by  school  teachers.  134 

gonorrhea  and  syphilis,  knowledge  of 103 

Syphilis    148 

Wassermann  test  for    148 

Syphilis  and   gonorrhea,  cooperation  of  all  authorities 104 

field  of  public  health  nurse  in  suppression  of  103-104 

infected  persons  must  not  care  for  children,  103 

recreation  as  means  of  controlling 104-105 

reporting  suspicious  cases  to  family  physi- 
cian or  health  officer 102 

social  agencies,  cooperation  of 103-104 

social  welfare  work 102-105 

three  classes  of  patients 101 

System  of  card   records    v 

sewage  disposal  in  relation  to  water  supply 55 

Tastes  and  odors  in  milk 41 

water    60 

Teeth,  decayed,  effect  on  health 196 

Tenement  houses,  control  of 226 

Terminal  fumigation   133 

Tetanus     146 

antitoxin     140-147 

Tonsils,  effect  on  health  of  infected 196 

Topography,  in  relation  to  water  supplies 54 

Toxin-antitoxin  treatment    143 

Types  of  dwellings    226 

personality  developing  insanity 220 

Typhoid  carriers   145 

fever    145 

specimens    145 

tests    145 

vaccine    146 

Tubercle  bacilli  in  milk 40 

in   sputum    144 

Tuberculin    110 

Tuberculous  cows,  preventing  infection  from 110 

children,  care  of    118 

who  are  feeble  minded 222 

family,    cooperation    and    division    of    duties    among 

workers   with    124-126 


Index  259 

PAGE 

Tuberculosis    144 

after-care  for  discharged  sanatorium  patients 118 

bovine    45 

campaign,  organizing  a    128 

classification  of  cases  of 107 

communicable  diseases  occurring  in  family 121-122 

compilation  of  laws  relating  to 117 

deaths  from  106 

dental  service  for  cases  of 122 

discovery  of  cases  of 113 

disposition  of  patients 116 

duty  of  person  having 110 

early  diagnosis  in 108 

family  in  an  insanitary  home 122-123 

food  handling  by  persons  having 110 

habits  of  persons  having 110-111 

home  supervision  of  cases  of 118 

home   treatment   of 117 

in  cows   110 

institution  cases   117 

isolation  of  cases  of 109 

laboratory  examinations  for 109 

laws,  compilation  of 117 

maternity  cases  in  family , 122 

measures  for  prevention  and  control  of 108 

medical   emergencies    120-121 

milk  and  eggs  for  patients  having 127-128 

other  forms  of    127 

prevention,  for  children 118 

procedure  and  precautions  to  be  taken  by  patients  having  109-110 

procuring  funds  for  worlv  in 129 

records    113 

relief    123-124 

reports  of  suspected  cases  of 109 

right  of  entrance  and  inspection  in  cases  of 127 

sanitary  instruction  in  cases  of 118-120 

sanatorium  treatment  for  cases  of 109,  111 

spontaneous  pneumothorax,  in  cases  of 121 

survey     112-113 

Tuberculosis  nurse     112 

collecting  sputum  specimens 113,  114 

county     112 

discoverv  of  cases  by 113 

duties  of    112, 115 

house  to  house  canvass  by 114 

mtmicipal    112 

reporting  suspected  cases  to  health  officer 112,115 

survey  by   112, 113 

visiting    reported    cases 114 

Uncleanliness  as  factor  in  spreading  disease., 225 

Underground  water    55 

Unrecognized  cases  of  communicable  disease,  discovery  of 19,  98 

Unreported  births    190 

cases  of  commimicable  disease,  discovery  of 19 

duty  of  health  officer  re- 
garding    98 

investigation  of    20 


260  IXDEX 

Ventilation,  efficiency  of   228 

lack  of  ' 225 

mechanical    230 

methods  of  227-230 

natural    230 

Vermin,   control   of 87-93 

of   bed   bugs    92 

body  lice    92 

head  lice    91, 92 

itch  mites    93 

Vincent's  angina     141 

smear  for  laboratory  examination  for 142 

Violation  of  rules  affecting  public  water  supplies 35 

Visiting  homes  of  venereal  disease  clinic  patients 103 

reported  communicable  disease  cases  and  contacts  94 

reported  tuberculosis  cases 114 

Vital  statistics,  abortions    160 

birth   certificates    166 

comparisons    of    rates 162 

conditions    affecting   rates 170-171 

corrected  death  rates    164 

death  certificates 166 

death  rates 161 

estimates  of  population 161 

fatality   rates    164 

infant  mortality  rates 165 

law  in  relation  to  stillbirths 186 

relating  to  reporting  of  births 186 

local  registrars   166 

marriage  as  affecting  moA-ement  of  population 162 

rates    165 

miscarriages     160 

morbidity  statistics   164 

movement   of    population 162 

natural  growtli  of  community 161 

necessity  for  registration  of 166 

population   in    relation   to ^ 160 

practical  use  of 168-170 

rates    162 

registration  districts   166 

specific  death  rates 163 

stillbirths   160,  186 

standard    population     165 

standardized  death  rate 164 

what  a  nurse  should  know  about 160 

Wassermann  test    148 

Water  analysis,  laboratory  report  of 59 

carriage  systems  of  sewage  disposal 72-73 

collection  of  samples  of 58,  62 

delffrKiii   (if  impurities   in 54 

disease   f^'criiis    in 53 

filtration    of    64-65 

liard     51 

impurities  in    52-53 

iron   in    52 

pure 50 

quantity  of,  used   in  household 51 

rain    53-54 

safe    54 


Index  261 

Water  —  Continued  page 

samples,  collection  of 58,  62 

sanitary   analysis  of 58 

sanitary  survey  of  supply 54 

sources  of  pollution  of 54-55 

Bupplies   19,  28,  50,  53 

inspection  of   31 

pollution  of   56-57 

prevention  of  impurities  in 63 

surface    54 

underground    55 

well    55 

Waterborne  diseases,  chemical   analysis   of 58 

investigation  of  methods  of  communication  of.  50,  53 

Watery    milk     41 

Weighing  and  measuring  children 180 

Wells     55 

protective  construction  of 57 

surface  pollution  of 56-57 

Widal  test  for  typhoid  fever 145 

Williams,  Dr.  Frank  E.,  types  of  personality  developing  insanity 220 

Wholesome    milk    44 

Whooping  cough   147 

vaccine    147 

"  Working  library  "  for  public  health  nurses 100 

Workshop,  hygiene  of  home  and 21 


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